tag:blogger.com,1999:blog-8229878121183426722Mon, 29 Apr 2019 09:35:59 +0000iatrogenicnosocomialunaidshivaidsprejudicestigmacosmetic servicesriskhospital transmitted HIVhospital acquired HIVinstitutional racismbehavioral paradigmblood-borne risksdevelopmentkenyaunderdevelopmentinstitutional sexismcircumcisionbehaviouralhiv industrybehavioural paradigmhospital acquired infectionsnosocomial infectionsexismmass male circumcisionVMMCmultinationalsaids industryinfection controliatrogenic transmissionhealthcommercial sex workbloodGates foundationself reliancepenile-vaginalhaisustainable developmentgenetically modified organismsGMeducationhiv preventionmen who have sex with menprostitutiondevelopment by omissionliesdeceptionhuman rightsmsmsolar cookersdeceithomophobiahomosexualityintellectual propertytechnical solutionsworld health organisationwater and sanitationgenetic modificationTBblood- borne riskschristian churchesnon-sexualsexual behaviourARTco-factorcondomseugenicsmalariamathematical 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desireshambashoe-horningshoehorningsisalslaveryslumssmoke inhalation.social capitalsocial mediaspousal searchstaravtionstatutory rapestereotypesterilizationsteroidstructuralsuperweedssurvivesweat shopssyphilissyringe reusesyringestanningtargetstattootax havensteacherstechnical advancestechnocracyteenageteenage pregnancytenofovirthefttrade agreementstrade related intellectual property rightstraditiontransporttreatment fundamentalismuanidsunited nationsunplanned pregnancyunplannedpregnancyunsafeunsafe injectionunsterilizedupstreamvaccinesvasectomyvaticanviolencevitamin Avoluntary testing and counsellingwanyororowaterborne diseasesway of lifeHIV in KenyaWelcome to my blog. HIV prevalence is not a reliable indicator of sexual behavior because the virus is also transmitted through unsafe healthcare, unsafe cosmetic practices and various traditional practices. This is why many HIV interventions, most of which concentrate entirely on sexual behavior, have been so unsuccessful.http://hivinkenya.blogspot.com/noreply@blogger.com (Simon)Blogger830125tag:blogger.com,1999:blog-8229878121183426722.post-1941956329125026964Thu, 11 Apr 2019 05:19:00 +00002019-04-11T08:19:59.429+03:00Antimicrobial Resistance and PrEP: Medical Disasters<div dir="ltr" style="text-align: left;" trbidi="on">Here are two antimicrobial resistance (AMR) scenarios, one rapidly spiraling out of control, and the other (arguably) incipient:<br /><br />The AMR scenario that is spiraling out of control is described in an article in <a href="https://www.nytimes.com/2019/04/07/health/antibiotic-resistance-kenya-drugs.html" rel="noopener" target="_blank">The New York Times</a>. The development of AMR is blamed on overuse and misuse of cheap antibiotics, usually without prescription. Ever-increasing use and misuse of antibiotics results in ever-increasing development of resistant strains of pathogens.<br /><br />The NYT article describes the appalling conditions that an estimated one billion people live in; slums where waterborne, foodborne and airborne pathogens thrive. Unable to escape the risks, people try to treat the symptoms with antibiotics, inevitably leading to resistance to most or all available treatments.<br /><br />The scenario described is a loop: widespread disease leads to overuse of antimicrobials; this leads to development of resistance; people with resistant conditions, if they survive, are taken to healthcare facilities, which also overuse antimicrobials, amplifying resistance and transmission of resistant strains; this loops back to the slum, resulting in an even higher disease burden, and greater levels of resistance.<br /><br />The loop could be broken by: 1) improving the environment, including water, sanitation, habitation, food, etc and 2) improving conditions in healthcare facilities, infection control, safety, hygiene, etc. This will reduce antimicrobial use and, therefore, resistance.<br /><br />The approach suggested by the <a href="https://www.gesundheitsforschung-bmbf.de/en/GlobalAMRHub.php" rel="noopener" target="_blank">Global AMR R&amp;D Hub</a>, on the other hand, risks speeding up the loop leading to AMR. They aim to “tackle the threat of resistant pathogens” by developing “new antibiotics and treatments against infections.” Producing antimicrobials of ever-increasing power, without addressing 1 and 2, above, only continues the cycle of ever-increasing resistance.<br /><br />The other scenario is described on websites such as <a href="https://www.iwantprepnow.co.uk/" rel="noopener" target="_blank">iwantprepnow.co.uk</a> (and <a href="https://prepster.info/about/" rel="noopener" target="_blank">prepster.info</a> and others). They advise on the use of PrEP (pre-exposure prophylaxis), antiretrovirals taken by HIV negative people to reduce the risk of HIV infection. For example, if "you have sex in a variety of situations where condoms are not easily used or not always used", PrEP, if properly used, can reduce risk of infection with HIV by more than 90%.<br /><br />There are (at least) two problems with this. Firstly, overuse or incorrect use of antiretrovirals can give rise to a resistant strain of HIV developing in an infected person, and that resistant strain can also be transmitted to others.<br /><br />Secondly, the advice from iwantprepnow.co.uk (and other similar sites, such as PrEPster.info) is aimed at people who frequently have sex without protection from other sexually transmitted infections (STIs). Exposing yourself repeatedly to infection with STIs increases the development of resistant strains of, for example, <a href="http://www.aidsmap.com/How-dangerous-is-gonorrhoea-resistance-and-can-it-be-halted/page/3398737/" rel="noopener" target="_blank">gonorrhea</a>, <a href="http://www.aidsmap.com/Multi-drug-resistant-iShigellai-detected-in-the-UK-and-USA-mostly-in-gay-men/page/3422429/" rel="noopener" target="_blank">shigella</a> and <a href="https://mosaicscience.com/story/sti-std-lgv-testing-diagnosis-symptoms-genitals-infection-sexual-health/" rel="noopener" target="_blank">Mycoplasma genitalium</a>.<br /><br />Use of PrEP without condoms also increases transmission of <a href="http://www.aidsmap.com/page/3469874/" rel="noopener" target="_blank">hepatitis C virus</a>: “Incidence of acute hepatitis C virus (HCV) among men who have sex with men who use PrEP in Lyon increased tenfold between 2016 and 2017”. HCV has doubled among HIV positive people.<br /><br />The <a href="https://www.csis.org/analysis/worlds-largest-hiv-epidemic-crisis-hiv-south-africa" rel="noopener" target="_blank">Center for Strategic and International Studies</a> spectacularly fail to notice the positive feedback mechanism, whereby <a href="https://www.jwatch.org/na48908/2019/04/09/prep-associated-with-higher-incidence-sexually-transmitted" rel="noopener" target="_blank">improper use of PrEP</a> could increase transmission of STIs and the development of resistance in countries where HIV prevalence is highest, sub-Saharan African countries:<br /><br />"In areas where there is so much HIV circulating, every sexual encounter is high risk, and widespread PrEP could be a prevention lynchpin." The same article even acknowledges that "High rates of sexually transmitted infections (STIs) increase the risk of HIV acquisition", without noticing how PrEP will increase STIs and resistance!<br /><br />According to The WHO, health is a "State of complete physical, mental, and social well being, and not merely the absence of disease or infirmity." In the two AMR scenarios described above, producing stronger antimicrobials and PrEP are examples of medicalization of health, viewing it as merely the absence of disease or infirmity. These kinds of medicalization will radically increase AMR.</div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/cdfR5ckGAmE" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/cdfR5ckGAmE/antimicrobial-resistance-and-prep.htmlnoreply@blogger.com (Simon)0http://hivinkenya.blogspot.com/2019/04/antimicrobial-resistance-and-prep.htmltag:blogger.com,1999:blog-8229878121183426722.post-223139490213764211Tue, 09 Apr 2019 12:00:00 +00002019-04-09T15:10:56.349+03:00Cherie Blair and ‘Rape in Africa’ Stereotypes<div dir="ltr" style="text-align: left;" trbidi="on">Cherie Blair was accused of perpetuating and reinforcing stereotypes and usurping African voices with her comment that “most African ladies’ first sexual experience is rape”. The <a href="https://www.theguardian.com/politics/2019/mar/26/cherie-blair-accused-of-reinforcing-stereotypes-of-african-women" rel="noopener" target="_blank">English Guardian</a> and <a href="https://www.npr.org/sections/goatsandsoda/2019/04/03/709072051/the-problem-with-cherie-blairs-statement-about-rape-in-africa" rel="noopener" target="_blank">NPR</a> both weigh in, with a number of reasons why Blair’s remarks were met with outrage.<br /><br />Critics of Blair are not wrong in calling her out on these comments. But they don’t go far enough. Yes, Blair should have acknowledged, for example, that rape and gender based violence are faced by women everywhere, not just in African countries. But Blair is only repeating stereotypes she would find throughout the mainstream media, and in a lot of specialized published sources.<br /><br />Blair is far from being alone in perpetuating and reinforcing stereotypes, such as those of the ‘promiscuous African’, ‘the violent African male’, ‘the widespread exchange of sex for money’, ‘the disempowered African female’, etc. Most of these stereotypes are a lot older than Blair, and date back to colonial times, at least.<br /><br />Nor have the long-held stereotypes mellowed with age. The bulk of HIV programming (and spending) is based on the very assumption that “<a href="https://www.ncbi.nlm.nih.gov/pubmed/14962531" rel="noopener" target="_blank">sexual transmission [is] the major mode of spread of HIV-1 in Africa</a>”, with some estimates suggesting that sex accounts for 80-90% of all transmissions in high prevalence countries (which are all in sub-Saharan Africa).<br /><br />On the subject of rape, the <a href="https://www.csis.org/analysis/worlds-largest-hiv-epidemic-crisis-hiv-south-africa" rel="noopener" target="_blank">Center for Strategic and International Studies (CSIS)</a> claims that: “Girls and women [in South Africa] also face an epidemic of rape and gender-based violence; many young women express more concerns about getting raped or getting pregnant than getting HIV. At one site we visited, the girls stated that getting raped was their number one fear.”<br /><br />CSIS was commenting on the fact that in some parts of South Africa, 60% of women are HIV positive. Many new infections are among girls 15-24 years old. However, the entire CSIS article assumes, without ever arguing for it, that all HIV transmission is sexual. This assumption may suggest that stereotypes such as those above are based on empirical findings, rather than being rank prejudice.<br /><br />Far from being based on research, stereotypes about ‘African’ sexual behavior are flatly contradicted by vast quantities of data collected by <a href="https://dhsprogram.com/Where-We-Work/Country-List.cfm" rel="noopener" target="_blank">Demographic and Health Surveys</a>, every five years, about sexual behavior in African countries. Just select any sub-Saharan country; rates of ‘unsafe’ sexual behavior are low, and there is little or no correlation with HIV prevalence.<br /><br />Cherie Blair is unlikely to have come across views that diverge from the mainstream prejudices about HIV in SSA, and that challenge those prejudices. But many of those challenges can be found, for example, in a <a href="https://www.ncbi.nlm.nih.gov/pubmed/19948893" rel="noopener" target="_blank">paper by John Potterat</a>, and in the bibliography for that paper. One of the main suspects in high rates of HIV transmission is unsafe healthcare; others are unsafe cosmetic and traditional practices.<br /><br />If Blair would like to reconsider the sort of stereotypes about sexual behavior and violence also expressed in the CSIS article, this is a good time to do so. Those outraged by her comments about ‘Africans’ and their alleged sexual behavior may wish to avail of the same research. Otherwise they all risk reinforcing and perpetuating stereotypes.</div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/n6CzPo4KeoQ" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/n6CzPo4KeoQ/cherie-blair-and-rape-in-africa.htmlnoreply@blogger.com (Simon)0http://hivinkenya.blogspot.com/2019/04/cherie-blair-and-rape-in-africa.htmltag:blogger.com,1999:blog-8229878121183426722.post-8263895876153718689Thu, 04 Apr 2019 16:18:00 +00002019-04-05T08:26:56.740+03:00Ebola: A Strategy of Misinformation?<div dir="ltr" style="text-align: left;" trbidi="on">In an article in The New England Journal of Medicine entitled ‘<a href="https://www.nejm.org/doi/full/10.1056/NEJMp1902682" rel="noopener" target="_blank">An Epidemic of Suspicion — Ebola and Violence in the DRC</a>’ Vinh-Kim Nguyen writes about violent attacks on Ebola treatment units and other health facilities. Nguyen argues that: "Epidemics thrive on fear — when they are frightened, patients flee hospitals, sick people stay away to begin with, and affected communities distrust groups trying to respond to the epidemic."<br /><br />But there's an important sense in which the opposite may be true. When people fear something that has proven dangerous in the past, avoiding that something may be the only rational response, the only way to avoid the danger. After all, several well-documented epidemics have been shown to thrive on unsafe healthcare. Examples are Ebola Virus Disease (EVD), hepatitis C (HCV), extensively drug resistant tuberculosis (XDR TB) and MRSA (Methicillin-resistant Staphylococcus aureus).<br /><br />The second ever outbreak of EBV, which occurred in <a href="https://en.wikipedia.org/wiki/Yambuku#Ebola_outbreak" rel="noopener" target="_blank">Yambuku (in Zaire) in 1976</a>, was a result of unsafe healthcare: "Peter Piot...concluded that it was inadvertently caused by the Sisters of Yambuku Mission Hospital, who had given unnecessary vitamin injections to pregnant women in their prenatal clinic without sterilizing the needles and syringes."<br /><br /><a href="http://origin.who.int/csr/don/31-january-2019-ebola-drc/en/" rel="noopener" target="_blank">WHO has recently announced that</a> "The outbreak [of EBD] in Katwa and Butembo health zones [in DRC] is partly being driven by nosocomial [=originating in a hospital] transmission events in private and public health centres. Since 1 December 2018, 86% (125/145) of cases in these areas had visited or worked in a health care facility before or after their onset of illness. Of those, 21% (30/145) reported contact with a health care facility before their onset of illness, suggesting possible nosocomial transmission."<br /><br />Globally, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4146761/" rel="noopener" target="_blank">hepatitis C virus (HCV) has infected an estimated 130 million people</a>.... [T]he wave of increased HCV-related morbidity and mortality that we are now facing is the result of an unprecedented increase in the spread of HCV during the 20th century. Two 20th century events appear to be responsible for this increase; the widespread availability of injectable therapies and the illicit use of injectable drugs. A significant <a href="https://www.albawaba.com/news/highest-rates-hepatitis-c-virus-transmission-found-egypt" target="_blank">healthcare associated outbreak occurred in&nbsp; Egypt</a> in the 1970s.<br /><br />Associated with poor infection control in health facilities, one of the <a href="https://en.wikipedia.org/wiki/Extensively_drug-resistant_tuberculosis#South_African_epidemic" rel="noopener" target="_blank">first outbreaks of XDR-TB</a> was discovered in Tugela Ferry Hospital, KZN, South Africa, in 2005. And a significant proportion of healthcare associated infections are <a href="https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/antimicrobialresistant-pathogens-associated-with-healthcareassociated-infections-annual-summary-of-data-reported-to-the-national-healthcare-safety-network-at-the-centers-for-disease-control-and-prevention-20062007/E0D85737B3C8D0AAE376156187AC75E7" rel="noopener" target="_blank">resistant to methicillin (ie, MRSA)</a>.<br /><br />Nguyen goes on: “In areas where the epidemic response has not involved security forces...people ask to be vaccinated.”<br /><br />But rolling out vaccinations in environments where infection control is inadequate (for example, healthcare facilities) might increase the risk of viral strains developing resistance (for example, among healthcare practitioners). Going to a healthcare facility during an outbreak of Ebola may be the worst thing a person can do. When people didn’t go to health facilities during earlier outbreaks, case numbers were limited, and the outbreak didn’t last long.<br /><br />Nguyen has also highlighted the importance of trust, and the consequences of mistrust of authority, experts and science. But if people are right to question the safety of healthcare facilities, as it would appear from above considerations, how can the trust of people at risk of exposure to ebola and other pathogens be regained?<br /><br />As long as continued Ebola transmission is blamed on what is depicted as an irrational fear of healthcare and vaccinations, people will stay away from healthcare. Because their fear is far from irrational, it is supported by scholarly research, expert opinion and even communications from the WHO. XDR TB, MRSA, HCV and other outbreaks have been shown to be healthcare associated outbreaks. Healthcare facilities also contribute the lion’s share to anti-microbial resistance (AMR).<br /><br />Modern healthcare facilities are potentially dangerous places. If patients were informed about the dangers, they would know better how to avoid them, and healthcare facilities would be compelled to address those dangers. Some of the earliest EBV outbreaks occurred when people came together around healthcare facilities, and died out when healthcare facilities closed, often because healthcare staff had been wiped out by Ebola.<br /><br />Trust in healthcare in developing countries may be regained, slowly, if people are adequately informed about the greatest risks they face, such as poor infection control, lack of hygiene, AMR, etc. Trust will not be regained by dreaming up new misinformation, nor by reinforcing old misinformation.</div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/JqBxymHHew0" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/JqBxymHHew0/ebola-strategy-of-misinformation.htmlnoreply@blogger.com (Simon)0http://hivinkenya.blogspot.com/2019/04/ebola-strategy-of-misinformation.htmltag:blogger.com,1999:blog-8229878121183426722.post-7164595281183196127Tue, 12 Feb 2019 18:47:00 +00002019-02-12T21:56:07.889+03:00Guardian: Another Fine Press Excess Mess<div dir="ltr" style="text-align: left;" trbidi="on">If I wrote that health facilities may be contributing to the spread of diseases, such as Ebola (or HIV), I'd be accused of spreading scare stories. But because it's the English Guardian, and it's about sex in an African country, they can publish with impunity a story with the title '<a href="https://www.theguardian.com/global-development/2019/feb/12/ebola-vaccine-offered-in-exchange-for-sex-say-women-in-congo-drc" rel="noopener noreferrer" target="_blank">Ebola vaccine offered in exchange for sex, say women in Congo</a>'.<br /><br />A quick read through the article shows that the title is wholly unmerited. And even the <a href="https://abcnews.go.com/beta-story-container/Health/wireStory/ebola-outbreak-marks-months-health-centers-concern-60777854" rel="noopener noreferrer" target="_blank">WHO has acknowledged</a> that 86% of people infected with ebola in several hotspots have worked at or visited health centers recently. So the "deep mistrust of health workers" in the DRC may not be as misguided as the Guardian seems to suggest.<br /><br />The Guardian continues: "Suspicion of authorities and health agencies has further hampered efforts to contain the response". The Guardian tends to avoid suggestions that suspicion of health agencies is ever justified. They prefer to point the finger at gender based violence, sex, bats, women, corpse touchers, anything to avoid the admission that ebola outbreaks cannot possibly be a simple matter of individual behavior, traditional practices, etc.<br /><br />The article is not an isolated example of the Guardian's fantasies about exotic sexual behavior, occult practices, primitive people, violent men and hapless female and child victims, without power or agency. Another in the series had the title '<a href="https://www.theguardian.com/global-development/2017/dec/08/hospital-bills-health-centres-sub-saharan-africa-asia-starved-abused" rel="noopener noreferrer" target="_blank">Women in sub-Saharan Africa forced into sex to pay hospital bills</a>', based on research that did not warrant anything so salacious.<br /><br />A third article in the Guardian screams "<a href="https://www.theguardian.com/global-development-professionals-network/2016/may/28/we-dont-know-enough-about-menstruation-and-girls-are-paying-a-price" rel="noopener noreferrer" target="_blank">Girls are literally selling their bodies to get sanitary pads</a>", which is a quote from a researcher more anxious to get publicity for her work than to address some very serious issues in developing countries. Read the research in question and you will not come away with the impressions that the Guardian would have us believe.<br /><br />And a fourth claims that <a href="https://www.theguardian.com/global-development/2017/dec/01/dating-app-technology-blamed-spike-hiv-rates-pakistan" rel="noopener noreferrer" target="_blank">dating apps in Pakistan</a> (a very low HIV prevalence developing country, where several outbreaks of healthcare associated HIV have been described) are leading to an increase in transmission rates (there is no evidence of any correlation, let alone a causal connection, it’s just speculation).<br /><br />It's not just the English Guardian that plumbs the depths of tabloid journalism when it comes to 'Africa', nor are all the bizarre, not too credible and very badly researched issues always about sex. For example, some may remember reading articles about people on ARVs <a href="https://www.bbc.com/news/world-africa-14312425" rel="noopener noreferrer" target="_blank">eating cow dung because they had no other food</a>, in the BBC and elsewhere.<br /><br />This story was repeated in a few other countries. Less attention was given to a <a href="https://www.iol.co.za/dailynews/news/i-lied-about-eating-cow-dung-1265326" rel="noopener noreferrer" target="_blank">woman who said she made up the story</a> because she was told she would have to come up with something good in order to get money to buy food.<br /><br />Other stories that seem belittling and (often obviously) untrue include one about men who have anal sex having to use adult diapers, people renting out used condoms and washing them before renting them out again, assumptions about 'African' sexuality (<a href="http://news.bbc.co.uk/2/hi/health/3014763.stm" rel="noopener noreferrer" target="_blank">which can also be found on the BBC site</a>, for example), etc.<br /><br />Other news outlets that seem unable to resist trivial, belittling and often simply untrue stories about some African countries include IRIN (<a href="http://www.irinnews.org/report/92309/kenya-condom-recycling-highlights-gaps-in-hiv-prevention-programming" rel="noopener noreferrer" target="_blank">condom recycling</a>), and Reuters, whose articles, like the BBC's, are often used to back up newspaper articles, or are syndicated in African newspapers.<br /><br />Aside from being insulting and demeaning, especially to people from African countries and women, these stories deflect attention from extremely serious risks that people in developing countries face, such as unsafe healthcare (which has been shown to contribute to outbreaks of HIV, Ebola, TB, hepatitis C and others), lack of sanitary and reproductive health services and supplies, misuse of medicines and many others.<br /><br />The consequences of such irresponsible reporting by some of the most trusted news outlets go far beyond the often trivial gossip that purports to be news. If healthcare facilities are unsafe, people should avoid them, especially if authorities (and the press) try to cover up and lie about the risks, at least until healthcare associated outbreaks of deadly conditions are investigated and addressed adequately.<br /><br />But if unsafe healthcare is deadly, so is the press that lies about it, the press that slings muck at anyone who dares to suggest that ‘professionals’ don't always know best, the press that loves to brand people as 'denialists' if they don't fall in with whatever is currently fashionable in 'expert opinion'.</div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/YZDDV--YteM" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/YZDDV--YteM/guardian-another-fine-press-excess-mess.htmlnoreply@blogger.com (Simon)0http://hivinkenya.blogspot.com/2019/02/guardian-another-fine-press-excess-mess.htmltag:blogger.com,1999:blog-8229878121183426722.post-7929004839823588346Sat, 11 Aug 2018 14:00:00 +00002018-08-11T17:03:30.078+03:00Tanzania: Some Alternatives to Orphanages<div dir="ltr" style="text-align: left;" trbidi="on">In a previous blog I concluded that “<a href="https://dontgetstuck.org/2018/08/03/why-watoto-kicheko-orphanage-is-now-closed/">Long-term residential accommodation will not provide the child with the conditions they need to develop</a>”, and this view is shared by many people and organizations working in child protection in Tanzania. But it would be a mistake to conclude that current practices can cease without being certain of which alternative strategies can be developed to care for vulnerable children, and avoid separating them from their families.<br /><br />I don’t claim to be an expert in the field of child protection, and what I have written below is based on a relatively small amount of research and inquiry. I make it available in case it is useful to others doing similar or overlapping work.<br /><br />I briefly outline a number of alternatives, in no particular order. Some of these activities are already being carried out by NGOs in Tanzania or elsewhere; others are in need of further inquiry; some of them may be practiced but I have not found any details yet (this is just informal research!). The list is by no means exhaustive:<br /><br />1. Child protection monitoring is lacking in the Tanzanian social welfare system; there are probably too few social welfare officers, with too few skills; more importantly, residential care seems to be one of the few options they consider whenever child protection is involved; many social services are provided by private bodies and there is little that is available nationally<br />2. Mental health issues in mothers and other family members need to be addressed, especially post natal depression; mental health issues are a common reason cited for children being in institutions, and other research shows that post natal depression is rarely diagnosed, let alone treated<br />3. Maternal health issues: health problems during pregnancy, delivery and in the months after giving birth are numerous; maternal morbidity and mortality rates are very high in Tanzania; care for the mother must not exclude appropriate care for the child, especially if they are separated; care for the child must involve continued contact with their family<br />4. Newborn health issues: birth defects, disabilities, developmental problems and doubtless many preventable and/or treatable conditions are common; infant and under 5 mortality very high in Tanzania; where this results in the child being separated from the mother or carer the care must be monitored so that the child is reunited as quickly as possible, and does not lose touch with the family at any time<br />5. Infant feeding and support for mother/carer/family is an important intervention that has been implemented in various forms in Tanzania for a long time, both large and small scale programs; but this needs to be available to all children, if required; timely programs have prevented a lot of separations of children from their mother/carer, and continue to do so<br />6. Support and acknowledgement for carers; sometimes the nominated carer has a very low status (social status, legal status, etc) in the family and is not considered to have an integral connection with the child’s welfare; there’s little point in the child bonding with a carer who will soon disappear, to be replaced by another carer, who may have a similarly low status<br />7. Home support for children with special needs; rare in Tanzania to find any kind of support for children with special needs or their carers; what is available is generally provided by NGOs and other private providers<br />8. Respite care for carers; such care may be provided by some NGOs but it is rare; informal respite care can be provided by relatives and friends/neighbors but this can carry serious risks, and many carers are completely isolated and without support of any kind<br />9. Daycare facilities; several NGOs are providing daycare facilities but these are mainly ‘supply driven’, and arise when there is a provider willing to build and run them; being able to send young children to daycare facilities would allow mothers/carers to work without having to worry about leaving their children in riskier circumstances, or leaving them with young siblings, who will then have to miss school<br />10. Foster care, formal, informal, long and short term; informal foster care is and has been common in Tanzania for a long time, although there is little recognition of the word or concept; there is legislation covering formal foster care but it doesn’t seem to be used much; social welfare tend to be reluctant to try out ‘new’ things<br />11. Family centered support in the home, eg, financial support, especially where there are indications of poverty, neglect, abuse; families are expected to provide care for children, even children of relatives, also old people, people with special needs, etc; yet many families live in poverty and isolation from healthcare, education and infrastructure; nothing is free when you have no income, so ‘free’ school and healthcare, for example, still involve costs that families struggle to meet, or fail to meet<br />12. Facilities that care for couples, infant/child and mother/carer, when required; rather than separating infants from mothers or carers in the event of sickness or death, providing facilities that allow them to remain together would significantly increase the child’s chances of thriving and even surviving, and also reduce the risk of separation<br />13. Specialist facilities for children who can't be at home; special needs often cannot be addressed adequately at home; sometimes a child has so many needs that the family can’t provide that they must spend some time in a specialist facility; but there needs to be better provision for keeping children in touch with their family if they are separated; at present, maintaining contact between children and families is down to the individual provider<br />14. Support for childless families, those who have experienced loss, stillbirths, etc; fostering and adoption by Tanzania families should be addressed and those who have lost a child, or families who are childless, are often interested in considering caring for a child who has been separated from their family and cannot return<br />15. Support for facilities reuniting children with families; generally, once a child has been placed in a facility, little effort is made to consider reuniting them with their family; often, families don’t even visit children once they are in a facility; reuniting them with their families can involve a lot of negotiation and logistics that facilities cannot afford, but reuniting them should always be the first concern for facilities and others working with child protection<br />16. Working with fathers/birthing partners, to encourage women to consider not being alone during delivery and the days after birth; programs that focus on infants, children or women can effectively exclude men, even antagonize them; working with fathers during pregnancy and birth is only one way of including them and could have a significant impact on the tendency to place children in orphanages; working with fathers to understand and negotiate how they can support their partner through pregnancy and delivery and the early months (putting it prosaically, mothers are often afraid of healthcare professionals, but healthcare professionals are often afraid of fathers who turn up to support their partners!)<br />17. Investigate cases of 'abandonment' and other instances of children being separated; this is a legal/administrative issue that can be very vague when cited as a reason for referring a child to an orphanage; it’s difficult to ‘abandon’ a child without a lot of people knowing about it, so claims of abandonment should be treated with greater caution<br />18. Investigate cases attributed to 'alcoholism', as some of them may be something entirely different, or something treatable, but that drives the alcoholism; the term ‘alcoholic’ can be applied to anyone who drinks, especially when applied to a woman; some residential facilities are funded by churches that preach against even the slightest association with alcohol<br />19. Follow up HIV and TB infected children to find out why they are in facilities, where they often cannot benefit from funded programs that are available for those conditions; chronic conditions can prove difficult for families to deal with, but many children are successfully cared for at home, given the right support<br />20. Investigate cases attributed to 'abuse' to ensure that there is not some other treatable cause that has been categorized as abuse; families are generally reluctant to discuss abuse openly, so it must be questioned when it is used as a reason for admitting a child to an orphanage; of course, abuse does occur, and there are legitimate reasons for children to be separated from their family, and possibly referred to a facility, a foster family, etc<br />21. Investigate children for whom there is no identifiable reason for their being in a facility, no problem with the child, no problem with the mother/carer/parents/family; if a child is in a facility and no one is visiting them, they can be left without anyone considering their future care; facilities often don’t have the resources to regularly review children’s care plan and social welfare tend to leave such matters to the facility<br />22. Promotion of Early Childhood Education where this is not available; many children go to school late for various reasons and this can make it difficult for them to catch up; sending children to appropriate education institutions must become the norm; being in daycare or early schooling is preferable to being at home alone, in the care of young siblings or in the care of people who are neither trained nor motivated to look after the child<br />23. Promotion of inclusive education in public schools; sometimes the smallest reason can be used for delaying a child’s start at school, such as a very minor impairment or disability; for example, there’s no reason for most children with albinism to stay at home; some children out of school have special needs that can be met at state schools, preferably with appropriate measures where the special needs are more acute; waiting until an institution that can provide for special needs is identified, or until the child is older and can more easily access such an institution, leads to long delays<br />24. There are tools such as the 'Child Development and Monitoring Tool' (from the Suryakanti Foundation), which can help identify, treat and even prevent some conditions that give rise to children having special needs; special needs can include developmental, behavioral, learning, impairments, etc, so it’s important to accurately identify what needs a child has as early as possible<br /><br />There are many alternatives to ‘orphanages’ and ways of preventing separation of children from their family. But it will be a harder job to assess the needs of every child currently in an institution and reunite them with their family, or care for them more appropriately, than it was to refer them to the institution in the first place. The challenge is to follow Tanzania’s Law of the Child Act to the letter: an orphanage should always be a last resort, and it should not be seen as a permanent solution.<br /><br />The majority of Tanzanian families are poor, a lot are living below the poverty line, unemployed, unskilled and isolated from services they need to change things for themselves. Orphanages and NGOs, donors and sponsors have long been seen as a lifeline, a way of getting one or more children cared for and educated, perhaps so that they can do more for their family later. If resources and funding are to be reduced in one area of child protection, they must be redeployed elsewhere.<br /><br />But the proliferation of orphanages in a region such as Arusha has merely led to the expectation that more and more orphanage places will be provided. And children will continue to be referred to orphanages as long as a justification that is acceptable to social welfare can be found. Support, funding and sponsorship need be redeployed in ways that avoid separating families.<br /><br />This is a working document and it will continue to be developed if people make contributions, comments, criticisms, etc. Thank you in advance!</div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/slcxXgnv2T8" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/slcxXgnv2T8/in-previous-blog-i-concluded-that-long.htmlnoreply@blogger.com (Simon)2http://hivinkenya.blogspot.com/2018/08/in-previous-blog-i-concluded-that-long.htmltag:blogger.com,1999:blog-8229878121183426722.post-1250719940988956319Fri, 03 Aug 2018 13:23:00 +00002018-08-03T16:23:38.790+03:00Why Watoto Kicheko Orphanage is now closed<div dir="ltr" style="text-align: left;" trbidi="on">Supporters and followers of Watoto Kicheko Orphanage will have heard that we are now closed, and we are not admitting any more children. Although there were some big challenges over the four years Watoto Kicheko was open there was only one reason why we closed: the children all had somewhere else to go; most of them (about three quarters) were reunited with their own families. A small number were adopted (4), or were placed in facilities that can best provide for their specific circumstances (3).<br /><br />Out of 36 children admitted over a four year period, only about 19 probably needed to spend some time in a residential facility. About 7 of them probably needed to stay for a year or more. But about 17 had no convincing reason for being in a residential facility. About 29 out of 36 should have left the facility sooner than they did, and some of them should have left far sooner. Sadly, three of the children died while under the care of the orphanage. No child was ever admitted on the grounds that both parents had died.<br /><br />A number of children were admitted because they were in urgent need of care, sometimes medium to longer term care. And a few would certainly not be alive today if they had not received the treatment and care they got while they were staying at Watoto Kicheko. For this, we owe a debt of gratitude to the staff of Watoto Kicheko, specialists and staff at Selian Hospital (ALMC), staff from a number of other facilities and a whole host of others who visited, gave advice and assistance, supported us in various ways, sent money, gifts and the like.<br /><br />The Tanzanian Law of the Child Act is clear that orphanages should be a last resort, once every other option has been considered. For a long time now, orphanages seem to have been treated as the go to place for children. Many of the children, and sometimes their parents or carers, have needs that can be provided without the child being separated from their family. Once a child has been separated, for whatever reason, it can be difficult to reunite them. Being separated from their family is a significant harm in itself, aside from the many risks children in care face. The practice of placing children in orphanages when they have no need to be separated from their family must stop.<br /><br />Of course, there are situations when a child may need to be separated from a parent, carer, or even their family. Sometimes it is not possible for a child to return to a family member, or even to the family. Caring for children in such circumstances is difficult, as anyone involved in child protection knows. But even urgent measures that need to be taken, emergencies, situations where there are clear risks for the child, etc, must also include a strategy for keeping the child in contact with a carer, someone who will stay close to the child, at least until their future is clear.<br /><br />Long-term residential accommodation will not provide the child with the conditions they need to develop. Neither disability nor poverty are valid reasons for denying children a family life. If you are involved in researching or working with forms of non-residential care for children, reuniting children who have been in care, alternatives to orphanages and strategies for keeping families together in Tanzania, I would love to hear from you: Simon Collery – collery [at] gmail.com<br /><div><br /></div></div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/7X_ReEHb6fs" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/7X_ReEHb6fs/why-watoto-kicheko-orphanage-is-now.htmlnoreply@blogger.com (Simon)0http://hivinkenya.blogspot.com/2018/08/why-watoto-kicheko-orphanage-is-now.htmltag:blogger.com,1999:blog-8229878121183426722.post-2523462460538810035Tue, 12 Jun 2018 13:52:00 +00002018-06-12T16:52:10.950+03:00A Minor Revelation Short of a Pulitzer<div dir="ltr" style="text-align: left;" trbidi="on">Steven Thrasher has made the fascinating discovery that <a href="https://www.theguardian.com/commentisfree/2018/may/30/black-gay-men-aids-hiv-epidemic-america" rel="noopener" target="_blank">many of the HIV positive, gay men in the US are not white</a>, and he regularly reveals this to "incredulous audiences".<br /><br />If he enjoys sharing this so much, perhaps he'd be interested to know that <a href="http://hivinkenya.blogspot.com/2017/09/americas-other-epidemic-hiv-in.html" rel="noopener" target="_blank">most HIV positive people in some of the country's southern states are heterosexual and female, as well as black</a>.<br /><br />Indeed, the majority of HIV positive people in the world are black and heterosexual; and a majority of those black HIV positive heterosexuals are female.<br /><br />Even though the majority of new HIV infections are among men who have sex with men in the US, HIV prevalence is 7 times higher among African Americans than it is among white Americans.<br /><br />So HIV among men who have sex with men is, to a large extent, a result of sexual behavior. And HIV among people who inject druts is, to a large extent, a result of reusing injecting equipment.<br /><br />But HIV among heterosexuals is much less likely to be a result of unsafe sex. Even among men who have sex with men, it's receptive anal sex that carries the highest risk.<br /><br />Thrasher laments American art imagining Aids as white and in the past. Yet, imagining it as black, gay, western and in the present fails to include the vast majority of HIV positive people: they are black, heterosexual females, from developing countries; and sexual behavior is unlikely to conform to the common stereotypes of 'African' sexuality, either.</div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/v-UcM3FNIjo" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/v-UcM3FNIjo/a-minor-revelation-short-of-pulitzer.htmlnoreply@blogger.com (Simon)0http://hivinkenya.blogspot.com/2018/06/a-minor-revelation-short-of-pulitzer.htmltag:blogger.com,1999:blog-8229878121183426722.post-6445792385694628595Sun, 01 Apr 2018 10:29:00 +00002018-04-01T13:29:16.262+03:00Where to Put Sidibe's Deckchair?<div dir="ltr" style="text-align: left;" trbidi="on">It's only two weeks since <a href="https://dontgetstuck.org/2018/03/17/sidibe-i-say-whats-ethical/">Michel Sidibe publicly threatened UNAIDS employees ungrateful enough to speak out about sexual and other misconduct by their colleagues</a>. But the media has remained silent. Even the <a href="https://www.theguardian.com/global-development/2018/mar/14/un-official-questions-ethics-of-sexual-misconduct-victims-bizarre-speech-michel-sidibe-luiz-loures" rel="noopener" target="_blank">English Guardian, who ran the article</a>, and refers to Sidibe's speech as 'bizarre' in the title, has had nothing further to say about it.<br /><br />The article appears in the Gates funded 'Global Development' section of the newspaper and the following text appears on the same page: "Women's rights and gender equality - This series highlights issues affecting women, girls and transgender people. It is supported by the Ford Foundation, Mama Cash and the Association for Women's Rights in Development (AWID). It is editorially independent." (I especially like the last bit).<br /><br /><a href="http://www.innercitypress.com/unaids1burundi032318.html" rel="noopener" target="_blank">The Inner City Press has tried to break the silence</a>. They are a small media outlet which has tried to raise the issue, but has been stonewalled by UN officials. In fact, the same organization has been banned from covering UN affairs and from attending press conferences and similar events. For a time, Google removed Inner City Press from their news, allegedly after pressure from the UN, although this was later reversed.<br /><br />The Inner City Press has a long history of questioning the UN, which shouldn't be surprising in a media outlet. But they have now demonstrated how quickly the UN clams up when certain questions are asked, questions that the rest of the media seems to have agreed not to raise. (There's a Change.org petition to have Inner City's access to the UN restored).<br /><br />According to a <a href="https://www.theguardian.com/media/greenslade/2012/jun/20/unitednations-press-freedom" rel="noopener" target="_blank">Guardian article in 2012</a> a "reporter who works for a small investigative news site, Inner City Press, is in danger of being ejected from the UN correspondents association (UNCA) at the behest of journalistic colleagues." This refers to Matthew Lee, founder of Inner City Press.<br /><br />Sidibe and UNAIDS seem to have shifted considerably from the UN Charter's call for respect for human rights, and the world's media don't appear to be too bothered, either. Perhaps this is what the Gates, Ford, Rockefeller and other foundations, whose names appear alongside so many worthy initiatives, are paying for.</div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/eOZMMUtgiQI" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/eOZMMUtgiQI/where-to-put-sidibes-deckchair.htmlnoreply@blogger.com (Simon)0http://hivinkenya.blogspot.com/2018/04/where-to-put-sidibes-deckchair.htmltag:blogger.com,1999:blog-8229878121183426722.post-7814683644869067921Sat, 17 Mar 2018 13:52:00 +00002018-03-17T16:52:59.307+03:00Sidibe: I Say What’s Ethical<div dir="ltr" style="text-align: left;" trbidi="on">In 2010 a <a href="http://news.bbc.co.uk/2/hi/health/8546655.stm" rel="noopener" target="_blank">BBC article</a> reported: “HIV has become the leading cause of death and disease among women of reproductive age worldwide”. We are told that “One of the key issues… is that up to 70% of women worldwide have been forced to have unprotected sex. UNAids says such violence against women must not be tolerated.”<br /><br />UNAIDS Executive Director Michel Sidibe is quoted as saying: "By robbing them of their dignity, we are losing the opportunity to tap half the potential of mankind to achieve the Millennium Development Goals" and “Women and girls are not victims, they are the driving force that brings about social transformation”. So I assume his objection to forced sex is not just related to the risk of HIV.<br /><br />But when a senior UNAIDS officer resigns after allegations of sexual harassment and assault, Sidibe weighs in with an attack on ‘whistleblowers’ who made the allegations, saying they “lack ethics and morals”. He also praised the accused official as ‘courageous’ for resigning. The official was not charged with any offence.<br /><br />Even if the accused, Luiz Loures, was innocent, Sidibe seems to be attacking those who try to report instances of violence against women, protecting those who are accused, and turning a blind eye to those who abuse and pillory the ‘whistleblowers’ (who are really just people reporting a serious crime, but in a specific context, the workplace).<br /><br />Sidibe has <a href="https://www.theguardian.com/global-development/2018/feb/24/un-former-employee-call-for-inquiry-sexism-bullying-harassment" rel="noopener" target="_blank">accused a former colleague</a> who spoke out against the behavior of Luiz Loures of lying. These victims of Sidibe’s vicious attacks on anyone who dares to criticize UNAIDS are, effectively, accused of biting the hand that feeds them, a typical response of institutionally sexist institutions that have managed to repress criticism of this kind of behavior for decades.<br /><br />But these matters have gone way past institutional sexism. <a href="https://www.theguardian.com/global-development/2018/mar/14/un-official-questions-ethics-of-sexual-misconduct-victims-bizarre-speech-michel-sidibe-luiz-loures" rel="noopener" target="_blank">Sidibe’s intention is clearly to bully and threaten</a> anyone who wants to work for UNAIDS, but would object to being sexually assaulted, and would report it and fight it.<br /><br />“We know there are people taking their golden handshake from us here and knowing that they have a job and then attacking us. We know all about that. We know every single thing. Time will come for everything. When I hear anything about abuse of our assets, abuse of our things, I ask for investigation. Maybe these investigations are going on.”<br /><br />UNAIDS has produced a <a href="http://www.unaids.org/en/resources/presscentre/featurestories/2018/february/20180227_unaids" rel="noopener" target="_blank">5 point plan</a> “to prevent and address all forms of harassment for greater accountability and transparency”, the second point of which is “an open platform will be created for staff to report on harassment, abuse of authority or unethical behaviour within the organization”. But it sounds very much like those who report such things would ‘lack ethics and morals’, in Sidibe’s view.<br /><br />It seems clear enough that Sidibe is more concerned about protecting UNAIDS funding, the institution itself and the top jobs than about fighting harassment and forced sex. But I don’t think it’s possible to reconcile the seemingly contradictory positions Sidibe is taking. On the one hand he defends women “forced to have unprotected sex”; on the other he attacks those raising concerns about serious sexual misconduct.</div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/xLUd-i4B3MY" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/xLUd-i4B3MY/sidibe-i-say-whats-ethical.htmlnoreply@blogger.com (Simon)0http://hivinkenya.blogspot.com/2018/03/sidibe-i-say-whats-ethical.htmltag:blogger.com,1999:blog-8229878121183426722.post-8546324657367182275Thu, 08 Feb 2018 12:01:00 +00002018-02-08T15:01:18.450+03:00Almost Positive: HIV Transmission Modes<div dir="ltr" style="text-align: left;" trbidi="on">Yet <a href="http://sci-hub.tw/10.1097/qai.0000000000001567" rel="noopener" target="_blank">another study</a> delves into the socio-economic, behavioral, biomedical and sexual lives of young girls, this time in Malawi. The study identifies 15 factors said to relate, directly or indirectly, to HIV transmission. But yet again, all HIV transmission is assumed to be sexual, all risks are assumed to be risks of sexual transmission, and no non-sexual risks or modes of transmission are considered. (If the link doesn’t work there is an abstract on <a href="https://www.ncbi.nlm.nih.gov/pubmed/28991885" rel="noopener" target="_blank">PubMed</a>).<br /><br />One of the hopes is that those selling pre-exposure prophylaxis (PrEP) will be able to ‘target’ people thought to be most at risk of being infected. However, there is little point in targeting those who are not at risk, or even those who don’t believe they are at risk. Pre-exposure prophylaxis doesn’t work if people don’t take it frequently enough, and those who don’t believe they face any risk are unlikely to take it at all.<br /><br />A scatter-gun approach would be very expensive and wouldn’t be very effective. But an approach that ‘targets’ people merely on the basis that they are sexually active is in danger of becoming a scatter-gun approach. So, on the one hand, this study (like many others) shows that most people don’t engage in the kinds of behavior said to carry a high risk of HIV infection (and many who do engage in them remain HIV negative).<br /><br />But on the other hand, this study fails to acknowledge that the assumption that all risk is, directly or directly, related to sexual risk, is completely unwarranted. It is concluded that PrEP can be ‘targeted’ at women who are at risk, but that more work will need to be done to convince these women that they are at risk, and that that risk is either directly or indirectly sexual. (There’s a favorable commentary on the article on <a href="http://www.aidsmap.com/page/3210325/" rel="noopener" target="_blank">AidsMap.com</a>).<br /><br /><a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3111352" rel="noopener" target="_blank">Another study</a> takes up the question of <em>whether</em> most transmission is sexual and, therefore, whether most risk is in some sense sexual risk. It does so by considering similarities among HIV genetic sequences, in order to identify possible sexual links. This study finds that only a small minority of clusters of sequences have identifiable sexual links.<br /><br />This study goes on to note that there is plenty of useful data available: tens of thousands of people in African countries were followed and thousands of new infections were observed among them, but less than 10% of these were attributable to sexual transmission; also, there have been numerous HIV outbreaks outside of Africa which have been a result of unsafe healthcare (all are <a href="https://dontgetstuck.org/cases-unexpected-hiv-infections/" rel="noopener" target="_blank">documented on this site</a>). Yet, none have been investigated in Africa.<br /><br />This is not such good news for PrEP, because non-sexually transmitted HIV is likely to be better addressed in other ways. But it could be great news for people in high prevalence countries. Sexual behavior and its determinants are notoriously difficult to influence, but conditions in healthcare facilities should prove more tractable. In addition, people need to be made aware of the non-sexual HIV risks so that they can avoid them, at least until conditions in healthcare facilities are improved.</div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/G0J1w9z7c0w" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/G0J1w9z7c0w/almost-positive-hiv-transmission-modes.htmlnoreply@blogger.com (Simon)0http://hivinkenya.blogspot.com/2018/02/almost-positive-hiv-transmission-modes.htmltag:blogger.com,1999:blog-8229878121183426722.post-1170153795168117826Wed, 17 Jan 2018 13:59:00 +00002018-01-17T16:59:50.430+03:00Sexual Stereotyping and Relative Discomfort<div dir="ltr" style="text-align: left;" trbidi="on"><a href="https://www.theguardian.com/lifeandstyle/2018/jan/13/black-woman-always-fetishised-racism-in-bedroom" rel="noopener" target="_blank">In an article about a nightclub in the south of England</a>, where couples can go one night a month so that the woman can have sex with black men while their male partner watches, Afua Hirsch is not so much concerned about the behavior of the clubbers as she is about the sexual stereotyping and racist assumptions that go with the concept of a ‘Black Man’s Fan Club’.<br /><br />Someone accompanying the author objects to the fetishization of black men and women that she experiences when she goes to swingers events, elsewhere. Another woman finds that, while many black men have relationships with white women, black women tend to be ignored, by white and black men.<br /><br />The article mentions sexual stereotypes about male and female black people and some of the problems this can give rise to, noting assumptions about black women having ‘voracious sexual appetites’ and the men being well endowed, dominant, having ‘better rhythm’, etc. It is suggested that even some black people, especially men, buy into this ‘hypersexuality myth’.<br /><br />Without wishing to diminish the importance of highlighting this crude sexual stereotyping of ‘African’ sexuality and sexual behavior in rich countries, I’m surprised that the author doesn’t take the article in the direction of some of the, arguably, more serious consequences of this kind of ‘exceptionalism’.<br /><br />For example, most HIV transmission in rich countries, such as the US, is found among men who have sex with men; a smaller proportion is a result of reusing injecting equipment by intravenous drug users. Among heterosexuals, transmission is far lower. But in high HIV prevalence African countries the bulk of transmission is among people who neither engage in male to male sex, nor inject drugs.<br /><br />Extremely high rates of transmission in certain parts of sub-Saharan Africa are attributed to this same set of assumptions about ‘African’ sexuality. We are told stories of vicious, predatory males having frequent and reckless sex with women who are depicted at times as being innocent victims, but at other times as having an amazing sexual appetite.<br /><br />Even articles that need not mention sexual behavior, or need not concentrate on it almost exclusively, often do so when the context is a high HIV prevalence African country. For example, a <a href="https://www.chathamhouse.org/sites/files/chathamhouse/publications/research/2017-12-06-hospital-detentions-non-payment-yates-brookes-whitaker.pdf" rel="noopener" target="_blank">study about women being held in hospitals until bills are paid</a> makes brief mention of a claim that someone had sex with a doctor to help cover her bills. But <a href="https://www.theguardian.com/global-development/2017/dec/08/hospital-bills-health-centres-sub-saharan-africa-asia-starved-abused" rel="noopener" target="_blank">an entire newspaper article about the report</a> revolved around that claim.<br /><br />Another <a href="https://www.theguardian.com/global-development/2017/aug/23/women-girls-bear-brunt-of-uganda-high-hiv-rate-national-survey" rel="noopener" target="_blank">newspaper article pathologizes sexual behavior in Uganda</a> by depicting it as the main reason for the extremely high rates of HIV transmission there. While the risk of being infected with HIV is much higher in Uganda than in most other countries, <a href="https://dontgetstuck.org/2017/08/30/is-that-guardian-article-really-racist/">sexual behavior there is unremarkable</a>, with a few people engaging in a lot of sex, but most people not doing so.<br /><br />Another example, although there are plenty around, of sexual behavior being exceptionalized and pathologized in African countries is an article about <a href="https://dontgetstuck.org/2017/01/07/questionable-research-are-menstrual-cups-a-hard-sell/">15 year old girls ‘selling their bodies to buy sanitary pads’</a>. A very small number of 15 year old girls surveyed made the connection between transactional sex and sanitary pads, but <a href="https://www.theguardian.com/global-development-professionals-network/2016/may/28/we-dont-know-enough-about-menstruation-and-girls-are-paying-a-price" rel="noopener" target="_blank">the newspaper article revolves around the claim</a>.<br /><br />Afua Hirsch is right about this racial stereotyping being demeaning, insulting and completely unacceptable, whether in a predominantly white and rich country or in a non-white and poor country. It could be argued, however, that the extent of racial stereotyping about sexuality and sexual behavior in the latter contexts is far more profound, even that it is dehumanizing. Or is it less remarkable because it’s ‘over there’ and not ‘right here’?</div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/1OaHLKJKUYA" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/1OaHLKJKUYA/sexual-stereotyping-and-relative.htmlnoreply@blogger.com (Simon)0http://hivinkenya.blogspot.com/2018/01/sexual-stereotyping-and-relative.htmltag:blogger.com,1999:blog-8229878121183426722.post-3187282513057439872Mon, 11 Dec 2017 13:04:00 +00002017-12-11T16:04:10.502+03:00Guardian Angles: Forced Sex to Pay Hospital Bills?<div dir="ltr" style="text-align: left;" trbidi="on">Chatham House has published a paper entitled '<a href="https://www.chathamhouse.org/sites/files/chathamhouse/publications/research/2017-12-06-hospital-detentions-non-payment-yates-brookes-whitaker.pdf" rel="noopener" target="_blank">Hospital Detentions for Non-payment of Fees: A Denial of Rights and Dignity</a>', the title being a good indication of what the article is about, and why a leading think-tank concerned with international affairs would research and report on such an issue.<br /><br />The practice of detaining patients in the grounds of a hospital until they pay their bills, with costs continuing to rise to cover their period of detention, is widespread in developing countries. Many people in those countries see it is unremarkable, even though it infringes on the rights and threatens the health of the poorest and most vulnerable.<br /><br />Relatively little research has been carried out, so the above paper suggests that its findings represent only a fraction of the severity and breath of the issue. But people can be subjected to all kinds of abuse while being held, aside from the abuse of being detained in appalling conditions.<br /><br />They can be denied vital health services, forced to live in inhumane and uninhabitable surroundings, subjected to physical, verbal and emotional abuse, without access to assistance or advice, without even the realization that healthcare establishments do not have the right to detain them in the first place.<br /><br />However, the details given in the Chatham House report do not justify the headline '<a href="https://www.theguardian.com/global-development/2017/dec/08/hospital-bills-health-centres-sub-saharan-africa-asia-starved-abused" rel="noopener" target="_blank">Women in sub-Saharan Africa forced into sex to pay hospital bills</a>'. The report does list an <em>allegation</em> that patients have "been pressured into having sex with hospital staff in exchange for cash to help pay their bills", also an <em>allegation</em> about "baby-trafficking".<br /><br />The Chatham House report links to what sounds like a very tenuous source for some of its findings, but they also refer to such items as 'allegations', as distinct from better supported findings.<br /><br />The newspaper article also cites several questionable assertions, including one about women having sex with 'doctors' for a few dollars to pay off bills that amounted to thousands of dollars, but without flagging up the potentially low credibility of the source.<br /><br />The newspaper article fits into a pattern of tabloid-style articles citing sources that ostensibly support their title and following assertions; yet, when you look at their sources, these turn out to give little or no support whatsoever. It's as if the article was published because it could say what the editor wanted to publish, rather than report what the journalist found.<br /><br />For example, an earlier article from the same newspaper about <a href="https://www.theguardian.com/global-development/2017/nov/17/aid-cash-transfers-improves-health-school-attendance-international-study" rel="noopener" target="_blank">giving aid in the form of cash transfers</a> is written as if this was found to be one of the most effective ways of providing assistance, but citing a <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011135.pub2/full" rel="noopener" target="_blank">report that came to the opposite conclusion</a>.<br /><br />The author of the hospital detentions article recently wrote about <a href="https://dontgetstuck.org/the-story-is-father-to-the-author/" rel="noopener" target="_blank">HIV in the Himalayas</a>, saying that she found that it was all the fault of the men, and that the women just had to put up with it. The men were 'migrant workers', who 'lied' about how they could have been exposed to HIV, and the woman remained silent, we are told.<br /><br />And another article in that newspaper blames a <a href="https://www.theguardian.com/global-development/2017/dec/01/dating-app-technology-blamed-spike-hiv-rates-pakistan" rel="noopener" target="_blank">rise in HIV transmission on 'dating apps'</a>, because 'every app is a dating app', according to the title. Perhaps this is an instance of what the New York Times refers to as <a href="https://www.nytimes.com/2017/12/05/magazine/the-return-of-the-techno-moral-panic.html" rel="noopener" target="_blank">'techno-moral' panic</a>, which can take anything currently fashionable, 'cyberporn' in the 90s, chat-rooms not long after that, sexting, online predators, etc, and vent their indignation.<br /><br />Remarkably, the article about dating apps purported to be about HIV in Pakistan, which is in the lowest quintile for HIV prevalence, globally. Although newspapers cling to the view that HIV is almost always a result of 'unsafe' sex, in Pakistan (and most other countries) there is ample&nbsp;<a href="https://dontgetstuck.org/2015/01/08/cambodia-hiv-thorough-investigation-or-pakistani-style-cover-up/" rel="noopener" target="_blank">evidence that there have been outbreaks caused by unsafe healthcare</a> in some of the highest prevalence areas, as well as in some low prevalence countries (Pakistan, Cambodia, etc).<br /><br />These journalist are happy to wallow in their favorite fantasies about ‘African’ sexual behavior, dating apps, transactional sex, trafficking and the like, almost as if they have to make up the story before an even less reliable source does so.<br /><br />At the same time, they distract attention from much more serious, but far less media friendly issues, without contributing anything to the problems that they claim to be drawing attention to in the first place, at least by highlighting topics that have been missed so far, but are in serious need of attention.</div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/siLHu51yNTE" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/siLHu51yNTE/guardian-angles-forced-sex-to-pay.htmlnoreply@blogger.com (Simon)0http://hivinkenya.blogspot.com/2017/12/guardian-angles-forced-sex-to-pay.htmltag:blogger.com,1999:blog-8229878121183426722.post-992294024805568632Sun, 26 Nov 2017 10:58:00 +00002017-11-26T17:09:48.280+03:00‘African’ Sexuality: Colonial Trope or New Racism?<div dir="ltr" style="text-align: left;" trbidi="on">An article entitled ‘<a href="https://research-information.bristol.ac.uk/files/48025781/Flint_and_Hewitt.pdf">Colonial tropes and HIV/AIDS in Africa: sex, disease and race</a>’ discusses the “idea of Africa as a place where health and general well-being are determined by culturally (and to a degree racially) dictated modes of sexual behaviour that fall well outside of the ‘ordinary’”. It raises some welcome questions about the claim that HIV is almost all caused by heterosexual behavior, but only in ‘Africa’.<br /><br />The authors continue: “By analysing historical responses to these two pandemics [syphilis and other STIs on the one hand and HIV on the other], we demonstrate an arguably unbroken outsider perception of African sexuality, based largely on colonial-era tropes, that portrays African people as over-sexed, uncontrolled in their appetites, promiscuous, impervious to risk and thus agents of their own misfortune.”<br /><br />This blog, and a small number of people writing about HIV in African countries, share Flint and Hewett’s disgust for “the promulgation of the European idea of African men as over-sexed and, by implication, predatory and dangerous and African women as over-sexed, promiscuous and shameless”. But the HIV bigwigs do not apologize for institutionalizing such prejudices, and never have.<br /><br />While Thabo Mbeki was disingenuous to claim that HIV does not cause AIDS, Flint and Hewitt support his claim that “the outsider view of Africans remains one of people who are ‘diseased, corrupt, violent, amoral [and] sexually depraved’”. The HIV industry has a tendency to brand anything they see as questioning their rigid stance as ‘denialist’. Mbeki’s questions remain unanswered, perhaps unanswerable, by an industry that refuses to apply scientific methods in a region where the overwhelming majority of HIV positive people live.<br /><br />Flint and Hewitt continue: “HIV/AIDS discourse can be seen to have slotted into an existing colonial narrative of the mysterious, unknowable and, above all, different, that was primed to accept the notion of HIV/AIDS in sub-Saharan Africa as a ‘disease of choice’ (with corresponding notions as to combating this perceived choice) – in remarkable contrast to ideas as to HIV/AIDS epidemiology and prevention <em>outside the continent</em>” [my emphasis].<br /><br />The industry had to tone down their notions of ‘good AIDS/bad AIDS’ in western countries; fashions change (or 'are changed'). But it was (almost) all ‘bad AIDS’ in ‘African’ countries, all someone’s own fault, all ‘avoidable’, if people would just follow advice to abstain, be faithful, avoid ‘traditional’ practices, embrace western style healthcare (albeit without western standards of safety, hygiene, funding or staffing).<br /><br />The attitude towards HIV in ‘African’ countries was especially reinforced by massive sources of funding, such as PEPFAR, “a programme influenced by and largely delegated to faith-based organisations, which engendered it, at times, with something of a crusading missionary outlook. Its emphasis on abstinence and fidelity suggested strongly that each person was broadly responsible for their own individual ‘salvation’: to be infected with HIV implied moral slippage”.<br /><br />Flint and Hewitt have squeezed a lot into a paper that covers so many issues, spread over a long period. However, I think they have neglected a few things that might have altered their conclusion, considerably. Firstly, they mention (in a footnote) David Gisselquist’s contention that the HIV pandemic could not have been caused by sexual behavior alone, and that unsafe healthcare practices might explain a significant proportion, perhaps even a larger proportion than sexual behavior.<br /><br />With the realization that the pandemic could not have been caused entirely by ‘African’ sexual behavior, isn’t there an immediate and urgent question about what else may have been involved? Reference is made to the preponderance of epidemiologists and other interested parties with their snouts in the trough, but the sheer weakness of the evidence for this assumed ‘African’ sexual behavior must also be examined. Epidemiologists have made it clear that they are certainly not going to revise their views and consider unsafe healthcare, or anything else.<br /><br />Secondly, I would also question Flint and Hewett’s claim that the line running from colonial bigotry about sexual behavior in Africa to today’s HIV industry’s institutionalized racist narrative of the HIV pandemic is ‘unbroken’ (and they do say ‘arguably’). The vitriolic hatred shown by people writing about sexually transmitted infections, ‘African’ sexuality and many other subjects was clear enough in the late 19th and early 20th centuries, continuing up to WWII, at least. But, I would argue, things changed.<br /><br />There was a phase of gradual enlightenment among writers of medical papers in the three or four decades preceding the identification of HIV as the virus responsible for AIDS. Flint and Hewitt even cite an early paper from one of those whose views were based on his own research in African countries, Richard Robert Willcox [<a href="https://sti.bmj.com/content/sextrans/62/2/135.full.pdf">obituary</a>]; and there were others who brought greater humanity to ‘colonial’ medicine, which had previously been viewed as just another instrument of control.<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1048300/">&nbsp;One example from Willcox will have to suffice for now</a>.<br /><br />Far from blaming STIs entirely on those who contracted them and transmitted them, Willcox and some of his contemporaries wrote that there are promiscuous people everywhere, and that STIs are mainly found among promiscuous people. But they also made it clear that the majority of people are not promiscuous; several of them might even have admitted that people in Africa were no more likely to be promiscuous than people elsewhere, which is anathema to the HIV industry.<br /><br />Thirdly, Flint and Hewitt don’t mention that many earlier estimates of diseases, assumed to be sexually transmitted, were distorted by the inability to distinguish non-sexually transmitted yaws and other diseases from syphilis. Figures purporting to show massive levels of endemic syphilis were not just exaggerated by the eugenicists, they were also empirically incorrect. Willcox knew that, as did many of his contemporaries.<br /><br />Outbreaks of STIs could also be explained by poor treatment programs, insanitary living conditions, labor conditions (especially in mines, armies, etc), resistance to medication, shortages in supplies, unsafe conditions in healthcare facilities, changes in epidemic patterns, lack of skills among personnel involved, shortages of skilled personnel, etc. Outbreaks of HIV could also be explained by such factors, if only more epidemiologists would accept that there is no disease that has a single cause, a cause entirely isolated from all other determinants of health, and that this unprecedented circumstance can only be found in certain African countries (a fifth of 'Africans' live in a region where HIV positive people make up 0.06% of the population).<br /><br />Numerous factors involved in STI epidemics, only a some of which are mentioned above, were recognized by many pre-HIV era writers. Therefore, those blaming disease outbreaks on ‘promiscuity’ and other ‘African’ behaviors, were bigots, not badly informed commentators. Some time after WWII, ‘colonial’ views about ‘African’ sexual behavior, at least in medical literature, became less common. It took a few decades, of course. But by the 1980s, when AIDS was recognized as a syndrome and HIV was identified as the cause, unbigoted views were frequently expressed about STIs and ‘Africans’.<br /><br />The extreme views of today’s HIV industry are not, I would argue, a clear continuation of colonial bigotry. Following three to four decades of increasing scientific rigor (and decreasing institutional racism), the emerging HIV industry of the 1980s had to develop its own form of racism. Many of the earliest proponents had little or no connection with the colonial past, although they adopted several of its more egregious ‘tropes’, being compatible with some of the extreme political and social attitudes also emerging at the time.</div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/2esi-XrsWvc" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/2esi-XrsWvc/african-sexuality-colonial-trope-or-new.htmlnoreply@blogger.com (Simon)0http://hivinkenya.blogspot.com/2017/11/african-sexuality-colonial-trope-or-new.htmltag:blogger.com,1999:blog-8229878121183426722.post-5237658732294834175Mon, 20 Nov 2017 14:05:00 +00002017-11-21T12:07:52.197+03:00It's the Truth, Bill, But Not as We Know It<div dir="ltr" style="text-align: left;" trbidi="on">"<a href="https://www.theguardian.com/global-development/2017/nov/17/aid-cash-transfers-improves-health-school-attendance-international-study" rel="noopener" target="_blank">Aid given in cash improves health and spurs school attendance, say researchers</a>", according to a title in the English Guardian. "Foreign aid in the form of cash transfers with no strings attached can improve health and increase school attendance, a study has found", claims the article. Yet, the conclusion of the study is "<a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011135.pub2/full" target="_blank">The evidence on the relative effectiveness of UCTs [unconditional cash transfers] and CCTs [conditional cash transfers] remains very uncertain</a>".<br /><br />The author, Hannah Summers, has been mentioned in a blog post here on the subject of<a href="https://dontgetstuck.org/2017/08/27/the-deep-racism-of-pathologizing-sex/"> racism, HIV and pathologizing sex</a>, and then in a <a href="https://dontgetstuck.org/2017/08/30/is-that-guardian-article-really-racist/">double take on the same set of issues</a>. On the subject of cash transfers, she writes as if her job, or her newspaper's future, depend on spinning this hyped strategy, which has been claimed to reduce poverty, influence behavior, improve health, and just about everything desirable you can think of.<br /><br />No mention is made in the Guardian about quality of evidence gathered by the study, which, in this instance, is astonishing: "Of the seven prioritised primary outcomes, the body of evidence for one outcome was of moderate quality, for three outcomes of low quality, for two outcomes of very low quality, and for one outcome, there was no evidence at all."<br /><br />This is not to say that handing out money to poor people had no discernable benefits. People with more money can, and often do increase spending on things like food, medicine, education, living conditions and a better environment (if cash transfers were ever to reach such dizzy heights).<br /><br />So it is no big surprise that people with more money, spending more on the above, will have fewer illnesses, improved food security, and perhaps dietary diversity, school attendance, etc. Nor is it a surprise that these improvements can lead to other improvements, given time and persistence.<br /><br />But is it necessary to carry out 21 studies, involving over a million participants and over 30,000 households to know that poor people need money, and that having more money will have health, education, social, environmental and other benefits?<br /><br />Is Summers entitled to claim that: "a review published this week flies in the face of criticism from the anti-aid brigade, showing that cash handouts have measurable benefits for some of the world’s poorest people." Is someone ‘anti-aid’ because they question her spin on this charade?<br /><br />At times, cash transfers look like a form of pimping. International NGOs and other recipients of funding for cash transfers take a big slice for themselves. Academics get grants for the inevitable studies, some consultants and experts depend on this kind of work for much of their (considerable) income, lots of well paid people are well paid by these 'initiatives'.<br /><br />Just in case the similarity to pimping is not clear, cash transfers have been used to induce people, mainly women and girls, to have less sex, to only engage in protected sex, to go to school (said to reduce sex, or ‘unsafe’ sex), etc. <a href="https://dontgetstuck.org/2015/08/02/paying-for-sex-and-paying-for-chastity-all-the-same/">If paying for sex is, at least in part, an attempt to control a woman's sexual or reproductive choices, then so is paying for chastity.</a><br /><br />If aid programs in their current forms are working, and need to be expanded, particularly certain types of aid program, why lie about the findings of a systematic review that explicitly questions conditional and unconditional cash transfers, and why would the English Guardian publish this obvious perversion of the findings of a Cochrane Review?</div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/anoN-Mrt1Ro" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/anoN-Mrt1Ro/its-truth-bill-but-not-as-we-know-it.htmlnoreply@blogger.com (Simon)0http://hivinkenya.blogspot.com/2017/11/its-truth-bill-but-not-as-we-know-it.htmltag:blogger.com,1999:blog-8229878121183426722.post-8015735966178066565Tue, 14 Nov 2017 13:55:00 +00002017-11-14T16:55:18.077+03:00The Story is Father to the Author<div dir="ltr" style="text-align: left;" trbidi="on">The story of '<a href="https://www.theguardian.com/global-development/2017/nov/03/emotional-journey-nepal-battle-with-hiv" target="_blank">How HIV found its way to a remote corner of the Himalayas</a>', is related in an article in the English Guardian. It was male economic migrants who went to India and "returned home with a very different legacy to the one [they] anticipated", infecting their partners, who then had children born with the virus. (But things are now improving because of the actions of the female victims.)<br /><br />Here's a comment on an 'interview' with one of the males who went to India to work: "Like many other men interviewed in Achham, Sarpa has a well-rehearsed story that explains how he believes he contracted HIV, but it does not involve any sex workers, whom researchers believe are the primary source of migrants’ HIV infections."<br /><br />Journalist Kate Hodal doesn't bother telling us how Sarpa says he was infected, preferring instead to believe the testimony of 'researchers'. How these researchers know that Sarpa is a liar, along with all the other people they have interviewed (and disbelieved), is anyone's guess. Perhaps they have some independent explanation or account of the HIV risks that people face in India?<br /><br />While Sarpa speaks "coolly", his wife Sita "has had to accept the likelihood [Sarpa] visited Indian brothels", indicating all this with a shake of her head.<br /><br />Hodal is clearly something of a psychic, who can know that while Sarpa lies, Sita tells the truth, but without uttering it. Hodal also knows that the opinion of researchers about HIV risks is of more value than the self-reported accounts of people who are infected, or who may become infected.<br /><br />Meanwhile in Canada, journalist Ashifa Kassam writes about a <a href="https://www.theguardian.com/world/2017/nov/08/canada-toronto-restaurant-hiv-aids-kitchen-staff-stigma" target="_blank">pop-up restaurant run by HIV positive people</a>. Far from pointing the finger at people with HIV, the article is about ‘challenging stigma’. The words of those interviewed are quoted, and their honesty is not in question.<br /><br />Population figures, numbers of people living with HIV, prevalence, even the breakdown by gender of those infected, are not vastly different in Canada and Nepal. Although Nepal’s epidemic is usually described as ‘concentrated’, in contrast to Canada’s ‘low-level’ epidemic, the two are remarkably similar in some ways.<br /><br />In contrast, in Canada, the vast majority of people are infected with HIV through unprotected, receptive anal sex and injecting drug use. But neither of those routes are thought to be so common in Nepal.<br /><br />However, there is a huge difference in the way HIV in Nepal and Canada are viewed by the media. In Canada, those with HIV are wholeheartedly encouraged to continue their fight against stigma. But in Nepal, the journalist writes something she may have believed before she left her desk: HIV is ‘spread’ by promiscuous men, to unwitting women and children.<br /><br />HIV positive Canadians can speak for themselves, and are not required to explain or justify their status. But Nepalese men need journalists and researchers to call them out on their lies about how they were infected; and Nepalese women need the same intermediaries to identify them as victims, unable to name the aggressors, or to speculate about how their partners became infected.<br /><div><br /></div></div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/FOHiQMAEO54" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/FOHiQMAEO54/the-story-is-father-to-author.htmlnoreply@blogger.com (Simon)0http://hivinkenya.blogspot.com/2017/11/the-story-is-father-to-author.htmltag:blogger.com,1999:blog-8229878121183426722.post-3370004111938869450Sun, 29 Oct 2017 13:59:00 +00002017-10-29T16:59:37.821+03:00HIV and Sex: Fallacy of the Single Cause<div dir="ltr" style="text-align: left;" trbidi="on">The four Kenyan counties of Kisumu, Homa Bay, Siaya and Migori that I mentioned in my <a href="https://dontgetstuck.org/2017/10/21/via-negativa-and-first-do-no-harm/">last blog post</a> have been in the news following the rerun of the presidential elections on Thursday 26 October. <a href="http://www.aljazeera.com/news/2017/10/kenya-election-rerun-171026071200911.html" rel="noopener" target="_blank">Voting in these four counties was suspended at an early stage</a> and scheduled to resume on Saturday 28, but they did not go ahead.<br /><br />The result of the presidential elections held in August was disputed in court, hence the rerun. But the opposition leader, Raila Odinga, later called for the elections to be boycotted, and turnout has been very low. The four counties in question are home to the majority of Odinga’s own Luo tribe, and a large proportion of people who might vote for him as president.<br /><br />Astoundingly, one third of all of Kenya’s 1.6m HIV positive people live in these four counties, even though only about one tenth of Kenyans live there. These counties make up the bulk of the former Nyanza Province, in the southeast. <a href="https://dontgetstuck.org/2017/10/19/via-negativa-the-way-to-low-hiv-prevalence/">In the blog post before that</a> I wrote about a contrasting area, where 0.2% of HIV positive people live: Mandera, Garissa and Wajir, the former northwestern province, with a population of about 1.6m (3.5% of Kenya’s population).<br /><br />In the earlier of these two posts I speculated that HIV prevalence in the northeastern counties may have remained low because of the geographical isolation of the area. Few roads go there, infrastructure is underdeveloped, health services are few and far between, and usage of health services tends to be low. Quality of health services is also likely to be low, but less harm can result if most people stay away from facilities.<br /><br />In the southwest, where infrastructure is a bit better, usage of health services is higher. This means that a lot more people are being exposed to potentially unsafe healthcare. Over 4m people live in 10,200 km2, compared to the 1.6m people in the northeast, an area of 127,300 km2. Population density can be lower than 10/km2 in the northeast and as high as 460/km2 in the southwest.<br /><br />Variations in sexual behavior don’t correlate very well with variations in HIV prevalence or distribution, so it can’t be the single or simple cause of HIV transmission. UNAIDS and other establishments involved in HIV programming claim that 80-90% of HIV transmission in high prevalence African countries is due to ‘unsafe’ sexual behavior, but they have never been able to demonstrate how such a claim could be true, or even plausible.<br /><br />However, it could be argued that variation in exposure to potentially unsafe healthcare practices correlates much better with HIV transmission. Both areas are isolated politically, and have been for many decades. Low usage of health facilities and social services (and low availability) seems to be a consequence of the political isolation experienced by the northwest. It is home to many of Kenya’s ethnic Somalis, a piece of land that was formerly part of Somalia.<br /><br />Down in the southwest, the politically isolated Luo population experienced a certain amount of growth and prosperity after independence, especially during the explosion in the population of Nile Perch in Lake Victoria. People with a bit more money are likely to spend some of that money on healthcare. But if that healthcare is not of high quality, is not safe, this might explain why wealthier people in high prevalence African countries tend to be more likely to be infected with HIV than poorer people.<br /><br />These two geographical areas have certain things in common: they are overwhelmingly populated by one ethnic group, and have both sought to distance themselves from the rest of Kenya; there has even been talk of complete political separation. But there must also be something very different about the two areas that explains why the HIV burden is over 160 times higher in the southwest than it is in the northeast.<br /><br />Search for ‘sexual reductionism’ on Google and you’ll come across a <a href="http://www.amnation.com/vfr/archives/014479.html" rel="noopener" target="_blank">discussion about a Vermeer exhibition</a> at the New York Metropolitan Museum of Art. This will give you some idea of how current HIV epidemiology seems to proceed. Apparently the texts accompanying the paintings treat every detail of the art works as being about sex.<br /><br />For UNAIDS, variation in HIV prevalence is all about sex: poor people sell sex, rich people buy sex, as do employed people, women are more vulnerable to sexual exposure than men, men are more promiscuous, sexual mores are different in Muslim communities, etc. But an alternative explanation is that variation in access to potentially unsafe healthcare facilities can better account for variation in HIV prevalence within and between geographical areas.<br /><br />The history of the isolation of the southwest and northeast counties of Kenya from much of the rest of the country, political, geographical, ethnic and other forms of separation, is a long and complex one. But so too is the history of the HIV epidemic, from its origins in equatorial Africa to its global spread, and the multiple causal factors that resulted in hyperendemic levels in some countries (and within some countries), but low levels in others.</div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/QY3otdZWCeM" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/QY3otdZWCeM/hiv-and-sex-fallacy-of-single-cause.htmlnoreply@blogger.com (Simon)0http://hivinkenya.blogspot.com/2017/10/hiv-and-sex-fallacy-of-single-cause.htmltag:blogger.com,1999:blog-8229878121183426722.post-5047929612040628109Sat, 21 Oct 2017 09:27:00 +00002017-10-21T12:27:41.290+03:00Via Negativa and ‘First do no Harm’<div dir="ltr" style="text-align: left;" trbidi="on">I am in favor of routine vaccination, for my children and for children in my care. I always take children to a doctor when there is something that won’t go away on its own, or that I don’t recognize, and I would do the same for myself. So I am certainly not advocating ‘doing nothing’ as a response to medical problems. I write as a layperson, with an interest in healthcare and development.<br /><br />But all healthcare must also be safe healthcare; people should be granted their right to know everything they need to know in order to make the best choices for themselves and their dependents, in accordance with the <a href="https://www.wma.net/policies-post/wma-declaration-of-lisbon-on-the-rights-of-the-patient/" rel="noopener" target="_blank">Lisbon Declaration on the Rights of the Patient</a>, along with other instruments relating to patient safety. I feel that people, especially in developing countries, are frequently denied these rights, and that the results of this can be fatal.<br /><br />In his <a href="https://dontgetstuck.org/2017/09/20/hepatitis-c-eradication-and-profit/">guest post for this blog, Helmut Jager</a> discusses the example of the infection of millions of Egyptians with hepatitis C (HCV) through unsafe healthcare, resulting in the highest prevalence of the virus in the world. Jager states that the “causes of the infections [globally] mostly are: bad medicine or intravenous drug addiction”.<br /><br />The ‘bad’ medicine Jager refers to is a program intended to reduce infection with schistosomiasis (bilharzia), caused by a waterborne parasite. This program involved the use of syringes, needles and perhaps other equipment that were not always sterile. Under such conditions bloodborne pathogens, in this case, HCV, can be transmitted from patient to patient.<br /><br />The medicine Jager describes is ‘bad’ because conditions in healthcare facilities are unsafe, instruments are being reused without adequate sterilization, etc. Rising numbers of people with HCV in the population eventually visiting health facilities meant increasing numbers of healthcare associated transmissions, also called ‘iatrogenic’; a vicious cycle.<br /><br />Jager is not suggesting that healthcare facilities should do nothing about schistosomiasis (or any other condition) in order to avoid the risk of iatrogenic transmission of HCV or other bloodborne pathogens. He is recommending that unsafe practices be eradicated, practices such as the reuse of injecting and other equipment and processes that involve piercing the skin, or even come in contact with bodily fluids, such as speculums, gloves, etc.<br /><br />Reducing unnecessary medicine is another of Jager's recommendations. The <a href="http://www.who.int/mediacentre/news/releases/2015/injection-safety/en/" rel="noopener" target="_blank">WHO estimates that 16 billion injections are administered globally</a> every year. In some countries up to <a href="http://www.starsyringe.com/wp-content/uploads/2016/05/WHO-Policy.pdf" rel="noopener" target="_blank">70% are probably unnecessary. About 37% were said to involve reused injecting equipment</a>. Therefore, reuse of other skin-piercing equipment may also add substantially to the problem.<br /><br />Jager’s blog is about the high cost of Gilead’s ‘sofosbuvir’ and the damage this does to programs aimed at eradicating the virus. Sofosbuvir has been recommended by the WHO for the treatment of HCV: it is unaffordable for people in poor countries, who make up the bulk of those living with the virus, at risk of suffering serious illness from it, and of dying from it. Jager cites a source reporting that “treatment costs in the US are US$84,000 and in the Netherlands €46,000. The production cost of the drug is estimated not to exceed US$140.”<br /><br />There are two man-made disasters here: first, there’s the raising of the Aswan Dam in the 1960s. The dam was intended to control the flow of the Nile in order to improve irrigation provision and generate hydroelectricity; this damaged ecosystems and led to an increase in schistosoma infestations. The second was the massive outbreak of HCV caused by unsafe healthcare procedures, employed to address the schistosomiasis endemicity, that affected millions of people.<br /><br />Apparently <a href="https://en.wikipedia.org/wiki/Environmental_impact_assessment" rel="noopener" target="_blank">environmental impact assessments evolved in the 1960s</a>, but it is likely there was something similar before the specific phrase was adopted. After all, it was known that introducing invasive species of fish to Lake Victoria would cause huge and irreversible problems early in the last century; the invasive species were introduced anyway, because certain parties wanted them to be (the colonials wanted to introduce sport fishing to the lake for their enjoyment). The fragility of ecologies has been recognized for a long time.<br /><br />Whether either or both these disasters could have been avoided 50 or more years ago, strategies to eradicate schistosomiasis sometimes seem to concentrate on a quick technical fix (there’s even a vaccine in development now), such as mass administration of Praziquantel. Praziquantel works, up to a point. It cures patients, and reduces the infected population, which promotes herd immunity and helps interrupt the life cycle of the parasite. But it is less effective in eradicating the parasite when used on its own.<br /><br /><a href="http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0005982" rel="noopener" target="_blank">Research in Lake Victoria finds that the population affected by schistosomiasis</a> also needs access to safe drinking and domestic water supplies, reduced contact with contaminated water, adequate waste disposal (which can interrupt the life cycle of the parasite), etc. In other words, the first disaster Jager alludes to, schistosoma infestation in the waterways, affects a much larger population than those who live close to and depend on the waters of the Nile.<br /><br />This is a larger and more general problem, because all massive infrastructure projects risk destroying ecosystems and environments. And the medical treatment people need once their water supply is infested can be too little; but possibly not too late. It’s too little because those affected will still need access to safe water and sanitation, but some of these issues can be addressed, bearing in mind the counsel of ‘first, do no harm’.<br /><br />Water and sanitation provision is vital, as is promotion of good health related information. Gilead are unlikely to scale back their profits much unless they are compelled to do so; yet, intervention would not be unprecedented. Unsafe healthcare can be eradicated, much more cheaply and efficiently than mopping up the victims of unsafe healthcare. And unnecessary healthcare can also be reduced, substantially, which will also reduce unsafe healthcare.<br /><br />In <a href="https://dontgetstuck.org/2017/10/19/via-negativa-the-way-to-low-hiv-prevalence/">my previous post</a> I speculated that counties in Kenya with very low HIV prevalence, such as Wajir, Garissa and Mandera, may have escaped high levels of transmission through unsafe healthcare by having very low levels of healthcare provision of any kind. I also speculated that high HIV prevalence in counties such as Homa Bay, Kisumu, Siaya and Mogori may be a result of greater access to healthcare facilities and health programs whose practices are not particularly safe.<br /><br />So those four counties on the shores of Lake Victoria, with fishing as one of the most important activities, must have very high rates of intestinal parasites (and other conditions). If use of health facilities is high, the chances of a pathogen such as HIV contaminating medical equipment, which is then reused without adequate sterilization, must also be high.<br /><br />Where healthcare is unsafe, carrying the risk of exposure to bloodborne pathogens, such as HCV, HIV and others through reuse of skin-piercing instruments, it’s best avoided; via negativa is the best counsel, even if most avoidance is a result of poverty now. There is still the option of ‘doing no harm’, but only if the contribution of unsafe healthcare to HIV epidemics so far is thoroughly investigated. If that's not done, people would be better off to stay away from healthcare facilities.</div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/Gr0N4G9fQZo" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/Gr0N4G9fQZo/via-negativa-and-first-do-no-harm.htmlnoreply@blogger.com (Simon)2http://hivinkenya.blogspot.com/2017/10/via-negativa-and-first-do-no-harm.htmltag:blogger.com,1999:blog-8229878121183426722.post-3506301045651132397Thu, 19 Oct 2017 13:00:00 +00002017-10-19T16:00:42.294+03:00Via Negativa: the way to low HIV prevalence?<div dir="ltr" style="text-align: left;" trbidi="on">Wajir is a city and county in Kenya’s former North Eastern Province. From a HIV perspective, the county stands out for having the lowest prevalence of all Kenya’s 47 counties, <a href="http://nacc.or.ke/wp-content/uploads/2016/12/Kenya-HIV-County-Profiles-2016.pdf" rel="noopener" target="_blank">currently estimated at 0.4%</a>. The next highest counties are Mandera (0.8%) and Garissa (0.9%). Wajir, Mandera and Garissa make up what was the province, formerly a part of Jubaland, in Southern Somalia.<br /><br />Homa Bay is a town and county in the south west, formerly part of Nyanza Province, and the number one county for HIV prevalence, 26%. Indeed, the only counties with prevalence above 10% are Siaya, Kisumu (19.9%), Migori (14.3%) and Homa Bay, which (along with Kisii and Nyamira) made up Nyanza. That accounts for one third of all HIV positive people in Kenya.<br /><br />The question of why HIV prevalence is so high in certain parts of Kenya is usually answered, implicitly or explicitly, with half baked notions about ‘African’ sexual behavior, ‘African’ mores, ‘traditions’, sexual practices, ‘unsafe’ sex, promiscuity. In a word: sex. It’s all about sex, and in the worst hit counties experts have persuaded the US to part with hundreds of millions of dollars for mass male circumcision programs.<br /><br />A lot less seems to be written about the extremely low HIV prevalence found in the north east. Look up Mandera, Garissa or Wajir on PubMed and you will only come across just over 300 papers altogether, compared to thousands for other locations (and almost 50,000 for Kenya as a whole). But it would be interesting to know how HIV prevalence has remained as low as in many western countries in the north west of Kenya, yet it has risen as high as the worst hit countries in southern Africa in the south west of Kenya.<br /><br />Sex happens in north eastern counties too. In fact, condom use is generally lower in these counties. Polygamy is more common, as are intergenerational sex and marriage, phenomena the HIV industry sometimes insists are risks for HIV transmission. Knowledge about HIV transmission and how to avoid it tends to be lower in these counties, too. Birth rates are higher than in other parts of the country.<br /><br />Circumcision is said to be widespread in a number of counties, not just in Wajir (and Mandera and Garissa) but also, for example, in Kilifi. But HIV prevalence in Kilifi is a lot higher, at 4.5%. The populations are predominantly Muslim in both counties, so circumcision is not likely to be the full explanation, nor is religion. There are commercial sex workers and men who have sex with men in every county, with no evidence that these practices are less common in low prevalence counties.<br /><br />The north eastern counties are, in fact, very different from the rest of Kenya. Kenya was divided up on ethnic lines by the British, which is why the territory once called the ‘Northern Frontier District’ became one province: it was, and still is, populated by ethnic Somalis. They are geographically isolated, in the sense that there are few major roads. Much of the north of Kenya is arid and sparsely populated. Even the Somalis who live elsewhere in Kenya, such as in Nairobi, tend to live in predominantly Somali suburbs.<br /><br />A similar kind of isolation, albeit on a much larger scale, can be found in northern Africa. The Sahara is sparsely populated and there are few major roads traversing it. HIV prevalence is low in all North African countries. In fact, HIV arrived relatively late in North Africa, and analysis of the common subtypes there suggest that the epidemic spread to a large extent from southern Europe, and to a lesser extent from West and central Africa.<br /><br />The most common HIV subtype in Kenya is type A, followed by D, with a small proportion of type C. But the most common subtype in the north east of Kenya is type C, this being the most common subtype in southern Africa, Ethiopia and a number of other countries. So the former province really does seem to have a different epidemic or ‘subepidemic’. Type C is known to have evolved later than A and D, so the former North Eastern Province’s subepidemic is newer, like those in North African countries.<br /><br />But it is still unclear how the above features of certain epidemics and subepidemics are associated with very low prevalence. Instead of looking for phenomena behind very high prevalence in some south western counties, are there certain phenomena that are absent in the north west (and in North Africa)? Isolation doesn’t mean less sex, nor even less ‘unsafe’ sex, and sexual behavior is very poorly correlated with HIV transmission.<br /><br />We don’t know much about Wajir, Mandera and Garissa because not much research has been carried out there, and it’s not surprising that little HIV research has been carried out where there's little HIV transmission. But what about other healthcare research? I notice almost all the articles on PubMed are about HIV, and were published in the last 20-30 years. So the area has been isolated from research for a long time.<br /><br />Now, if there are few roads and limited infrastructures, is healthcare infrastructure similarly limited? It could be expected that access to healthcare facilities is poor and that many people rarely or never go to a hospital, or see any kind of health professional. The majority of women probably give birth at home, coverage of mass drug administration programs, including routine immunizations, is probably lower for these and other more isolated counties.<br /><br />Borrowing Nicholas Nassim Taleb’s ‘via negativa’ in his book ‘Antifragile’, perhaps HIV prevalence in the north east of Kenya (and in North Africa) has remained low because of infrequent contact with healthcare facilities. This is not to say that healthcare facilities are unsafe in the north east, although it does suggest that they are unsafe in high prevalence counties. Also, it is suggested that HIV is circulating in health facilities, more in some than in others.<br /><br />Many (including Taleb) like to repeat that ‘absence of evidence is not evidence of absence’. There is a possibility that HIV has been, and is still circulating in health facilities in Kenya, and may account for a significant proportion of infections, perhaps the majority of infections. Little research has been carried out to estimate the relative contribution of healthcare associated HIV transmission. We will never know until the evidence is sought: does limited contact with healthcare keep HIV prevalence low in the north east of Kenya?</div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/jjB8so-bsyE" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/jjB8so-bsyE/via-negativa-way-to-low-hiv-prevalence.htmlnoreply@blogger.com (Simon)0http://hivinkenya.blogspot.com/2017/10/via-negativa-way-to-low-hiv-prevalence.htmltag:blogger.com,1999:blog-8229878121183426722.post-4882565247812502167Wed, 11 Oct 2017 15:38:00 +00002017-10-11T18:38:00.630+03:00UNAIDS: Still Spanking the Chimp<div dir="ltr" style="text-align: left;" trbidi="on">How are we to make sense of a HIV epidemic such as the one in Uganda? We are told that it is mostly a result of ‘unsafe’ sex. But data about sexual behavior in Uganda is unremarkable; most people don’t engage in high levels of unsafe sex, and types of sexual behavior considered unsafe appear not to be so unsafe after all.<br /><br />In 2007, it was estimated that there were almost one million people living with HIV, 135,000 newly infected with HIV in that year, and 77,000 deaths from Aids. The Demographic and Health Survey for Uganda in 2011 concluded that “<a href="https://dhsprogram.com/pubs/pdf/AIS10/AIS10.pdf" rel="noopener" target="_blank">Differences in HIV infection according to higher risk sexual activity are minor</a>”.<br /><br />In fact, the vast majority of the 18,000 people surveyed did not engage in sexual behavior considered to be risky. Most people had a maximum of one partner in the last 12 months, most who had more than one partner did not have concurrent (overlapping) partnerships, most did not report large numbers of lifetime partners, most didn’t pay for sex and most didn’t engage in ‘higher risk’ sex in the past 12 months.<br /><br />So it’s hard to believe that the table appearing on page 15 of the Modes of Transmission Survey (MoT) for Uganda, for 2009, can be anything but fiction. It claims that <a href="http://documents.worldbank.org/curated/en/677131468316469812/pdf/764180WP0Ugand00Box374375B00PUBLIC0.pdf" rel="noopener" target="_blank">almost 90% of HIV incidence is a result of multiple partnerships, partners of multiple partnerships and people engaged in mutually monogamous heterosexual relationships</a>.<br /><br />Even incidence attributed to sex workers doesn’t reach 1%, nor does that attributed to men who have sex with men, plus their female partners. Injecting drug use doesn’t play a big part in most of the epidemics in sub-Saharan Africa either.<br /><br />The DHS figures for Uganda clearly do not support the MoT figures. They do not support the contention that high HIV prevalence indicates high rates of ‘unsafe’ sexual activity; HIV prevalence is high in Uganda, but sexual activity is not exceptional, nor is it closely associated with HIV transmission.<br /><br />DHS continues: “HIV prevalence by the number of sexual partners in the 12 months before the survey does not show the expected patterns”. It is noted that “HIV prevalence shows the expected relationship with the number of lifetime sexual partners” but the author doesn’t mention that the numbers of people involved is very small. So they conclude that “it is important to remember that responses about sexual risk behaviours may be subject to reporting bias”.<br /><br />Uganda was one of the first countries to expose itself to the scrutiny of the rapidly developing HIV industry, from the 1980s. As a result, a lot more studies took place there, a lot more papers were published about Uganda and tens of millions more dollars were spent there than in any other African country, even countries that later turned out to have far worse epidemics.<br /><br />It takes more than a bit of fluffing to get from the Demographic and Health Survey’s flaccid data on sexual behavior to the conclusion that almost 90% of HIV transmission is a result of unsafe heterosexual sex. But if the industry doesn’t come clean about where the bulk of new infections are coming from, resources targeted at those thought to or claimed to engage in ‘unsafe’ sex will continue to be wasted.</div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/82WUNprLbKc" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/82WUNprLbKc/unaids-still-spanking-chimp.htmlnoreply@blogger.com (Simon)0http://hivinkenya.blogspot.com/2017/10/unaids-still-spanking-chimp.htmltag:blogger.com,1999:blog-8229878121183426722.post-2159109497860057219Thu, 28 Sep 2017 13:12:00 +00002017-09-28T16:12:23.422+03:00HIV: A Rich Seam in a Long Abandoned Mine?<div dir="ltr" style="text-align: left;" trbidi="on">Here's a stomach-churning quote from <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2984846/pdf/eugenrev00294-0052.pdf" rel="noopener" target="_blank">The Eugenics Review, 1932</a>: "East Africa [has] a heavily syphilized native population", where tests suggest that "not less than 60 per cent. to 70 per cent. of the general native population" have some kind of sexually transmitted disease.<br /><br />At that time, several conditions were mistaken for syphilis (or other STIs). For example, yaws and endemic syphilis, neither of which are sexually transmitted. Prejudices about 'African' sexual behavior were used to prop up beliefs about prevalence of STIs (and prejudices about STIs proped up beliefs about sexual behavior).<br /><br />You might think that things would have moved on a bit, what with eugenics no longer having the cache it had in the thirties, right? But the received view of HIV in high prevalence countries is that 80-90% of transmission is a result of sexual behavior, mostly heterosexual behavior.<br /><br />From this 'expert’ opinion about ‘Africa’, it is assumed that high HIV prevalence indicates high rates of 'unsafe' sexual behavior, and that high rates of 'unsafe' sexual behavior (or rates that are assumed to be high) indicates high HIV prevalence, or that prevalence will reach high levels in the foreseeable. It’s pretty easy to spot the pig-headed circularity in the argument.<br /><br />So, how far have we moved on 80 years after the Eugenics Review quote, above? Here’s <a href="http://aighd.org/people/catherine-hankins/" rel="noopener" target="_blank">Catherine Hankins</a>, from the Amsterdam Institute for Global Health and Development (formerly a senior officer in UNAIDS):<br /><blockquote><a href="http://news.bbc.co.uk/2/hi/health/3014763.stm" rel="noopener" target="_blank">As Hankins surmises, in some cultures what you do with your sexual partners over time is different. In the West we tend to be serially monogamous.</a><br />In Africa, if you've had sex with someone at some point, the door isn't considered closed on picking up on that relationship again.<br />"Take a middle-class African businessman. He has had five women - nothing excessive. But the pattern we find is that he has a wife. He also has an on-off affair with an office colleague. He also has what the French call a 'deuxième bureau' - a mistress who might have a child. And once a year he goes back to his home village and has sex with his original village sweetheart. Then he gets HIV from a bar girl on a business trip.<br />"Within a year he may have infected four other women. Now, if I've had five sexual partners and catch HIV from the fifth, as a western woman I'm unlikely to return to the other four and infect them!"</blockquote>You might object that it is unfair to criticize what is clearly just an opinion, however ‘expert’. But policy is based on such opinions, HIV programs are guided by them, enormous amounts of money are spent (entirely in vain) on them. Worse still, the scientific data so assiduously collected shows that Hankins is as wrong as the eugenicists. Ostensibly, at least, Hankins was responding to scientific findings, published in a scientific journal, not to someone's opinion.<br /><br />You can look through any <a href="https://dhsprogram.com/Where-We-Work/Country-List.cfm" rel="noopener" target="_blank">Demographic and Health Survey</a> you like, where you will find numerous tables about sexual behavior, family life, people’s ability to recall selective tidbits about HIV, etc, but you will not find a country where a large number of people have lots of sexual partners, or engage in sexual activities considered to be unsafe.<br /><br />In addition, the circularity mentioned above comes across very clearly in Hankins’ invective: HIV prevalence is high because rates of ‘unsafe’ sexual behavior are high, and we know about sexual behavior because HIV prevalence is high. Hankins clearly believes all these prejudices that she expresses about sexual behavior among ‘Africans’!<br /><br />Three countries account for about one third of all HIV positive people, globally; South Africa (6.8m), Nigeria (3.2m) and India (2m). The same three countries also accounted for more than half of all aids-related deaths in the past few years. It is notable that prevalence is low in India, at less than 0.3%. This compares to about 3% prevalence in Nigeria, and about 19% in South Africa, more than 60 times higher than in India (and it can rise to well over 100 times higher in certain demographics).<br /><br />Whatever is behind the huge rates of HIV transmission in these countries, which tend to be concentrated in certain geographical areas and populations, it is likely to be something that is amenable to scrutiny, whether it involves the copious quantities of sex that UNAIDS would claim, or something else, for example, dangerously low standards of hygiene and infection control in some health facilities.<br /><br />Hankins seems intent on mimicking the media approach to HIV, concentrating on relatively rare and infrequent phenomena (deliberate transmission, ‘virgin cures’, fake healers, ‘traditional’ practices, etc), but failing to notice the appalling conditions in healthcare in some of the areas worst hit by HIV. What is it that is deflecting attention from everyday phenomena, allowing such extreme views to prevail, but failing to reduce infections in the worst hit areas?</div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/eysRluRYhnM" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/eysRluRYhnM/hiv-rich-seam-in-long-abandoned-mine.htmlnoreply@blogger.com (Simon)0http://hivinkenya.blogspot.com/2017/09/hiv-rich-seam-in-long-abandoned-mine.htmltag:blogger.com,1999:blog-8229878121183426722.post-6398720638011933382Fri, 15 Sep 2017 10:29:00 +00002017-09-15T13:29:40.251+03:00Pre-Exposure Prophylaxis: Risks in the Pipeline?<div dir="ltr" style="text-align: left;" trbidi="on">An estimated 1 million Kenyans are receiving antiretroviral drugs, about <a href="https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/kenya" rel="noopener" target="_blank">64% of all HIV positive people</a>. Partly as a result of this, death rates, along with the rate of new infections, have continued a decline that started in the early 2000s, and the early to mid 90s, respectively. Now <a href="https://theconversation.com/kenya-embraces-new-prevention-efforts-to-reduce-hiv-infection-80483" rel="noopener" target="_blank">pre-exposure prophylaxis (PrEP) is being added to the country’s HIV strategy</a>, a course of antiretroviral drugs taken by HIV negative people, which should significantly reduce the risk of their being infected.<br /><br />So this should be a good time to look at how HIV treatment in its various forms should be targeted. ARVs are relatively straightforward, people testing positive can be put on treatment. But PrEP, if it is expected to reduce infections, needs to be prescribed for those most at risk. This is not as simple as it sounds, because HIV resources have so far been flung far and wide in Kenya, as if those who most need them will magically benefit.<br /><br />The ruling assumption for high prevalence countries has been that 80-90% of all HIV transmission is a result of ‘unsafe’ sexual behavior. HIV prevalence is seen as a reliable indicator of ‘unsafe’ sexual behavior, and ‘unsafe’ sexual behavior, or perceived behavior, is seen as a reliable indicator of prevalence.<br /><br />This is completely circular, of course. But if these prejudices are carried over from addressing the HIV positive population, and applied equally to the HIV negative population, the bulk of the drugs may as effectively be flushed down the toilet. The majority of Kenyans are, were, or will be sexually active. But the majority are not at risk of being infected with HIV.<br /><br />Kenya’s HIV epidemic, in common with the epidemics in several other East African countries, is quite old. The virus has been circulating since the 50s and 60s, so the epidemic is about half a century old, give or take a few years. In other countries, such as the DRC, the virus has probably been around for about 100 years, although it must have affected only small numbers of people for many decades.<br /><br />Don’t be fooled by figures suggesting that HIV has only been around since it was first recognized by doctors in the early 1980s (or just a little bit earlier), and later described by scientists. UNAIDS estimate that prevalence was already about 3% in Kenya by 1990, rising to over 10% later in the decade, to peak at almost 11%. From 2000, prevalence declined for a few years, rose again from 2005, then dropped to 6%.<br /><br />This suggests that the rate of new infections (incidence) peaked and started to decline in the early to mid 90s, prevalence peaked and started to decline by the late 90s, and death rates would have peaked in the early 2000s. By 2007 prevalence was 8% and it is now 6%, so it has hovered between 6 and 8% for more than 10 years. Declines are slow, irrespective of major interventions.<br /><br />Although the widespread use of ARVs, which began in the late 2000s, has contributed to a decline in new infections, prevalence and death rates, it is not possible to attribute these improvements to drugs alone. Making PrEP available to all those assumed to be ‘at risk’ of being infected, purely on the basis of the circular argument mentioned above means that this is going to be an expensive, but very ineffective intervention.<br /><br />This sounds like bad news, but it doesn’t have to be seen that way. If the HIV risks people face could be identified, whether they are sexual or non-sexual, this will reduce the number of people who need PrEP. Most non-sexual risks, for example, exposure to blood and other bodily fluids through unsafe healthcare, cosmetic and traditional practices, are easily and cheaply avoided. No need to give PrEP to all the patients at a clinic when you could just clean up the clinic, right?<br /><br />But also, things have changed, PrEP allows us to target those most at risk much more accurately than before. If people know they can protect themselves, they will. Clinics can now safely return to the practice of ‘contact tracing’, identifying how each person testing positive may have been infected, and then addressing that source of infection, whether it was a sexual partner, a clinic, a tattoo artist, or whatever.<br /><br />The decision to discontinue tracing contacts, which was made in a very different context (a rich country, where the bulk of HIV transmissions were occurring among a relatively small population, and resulting from an easily identified set of behaviors) is inappropriate for a country with a massive HIV epidemic, where the risks have not been clearly demonstrated, and averted. In Kenya, for example, the majority of people who become infected with HIV do not face the high risks identified in rich countries, receptive anal sex and injecting drug use.<br /><br />If identifying how people become infected can allow HIV negative people to avoid being infected, and allow HIV positive people to avoid infecting others, then contact tracing is vital in high prevalence countries. It is also vital if interventions such as PrEP are to be effective, or even affordable. Already, researchers have found that <a href="http://www.aidsmap.com/page/3168357/" rel="noopener" target="_blank">not being able to identify where the risks are coming from</a> will significantly increase the quantity of drugs each person needs, in addition to vastly increasing the number of people deemed to be in need of PrEP.<br /><br />Despite ample evidence that non-sexual risks are as important as sexual risks, evidence that has been available since the virus was first identified as causing Aids, most research concentrates on <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5520344/pdf/12889_2017_Article_4593.pdf" rel="noopener" target="_blank">reporting sexual risk only, collecting data about sexual risks, recommending strategies to reduce sexual risks only</a>, while ignoring, denying or failing to collect data on non sexual risks.<br /><br />Mass ARV rollout complements pre-existing trends in HIV epidemics, though not as much as it could have, had the contribution of non-sexual transmission been acknowledged. However, PrEP will be a slow and inefficient solution unless targeted at those truly at risk, as opposed to the tens or hundreds of millions who are sexually active. People can only protect themselves if they know what the risks are, whether they do it by avoiding exposure, or by taking prophylactic drugs.</div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/3znS_nNrpDY" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/3znS_nNrpDY/pre-exposure-prophylaxis-risks-in.htmlnoreply@blogger.com (Simon)0http://hivinkenya.blogspot.com/2017/09/pre-exposure-prophylaxis-risks-in.htmltag:blogger.com,1999:blog-8229878121183426722.post-7982497362665813883Tue, 12 Sep 2017 13:30:00 +00002017-09-14T14:27:09.487+03:00HIV in 'Africa':12 Steps to Unknowing Knowns<div dir="ltr" style="text-align: left;" trbidi="on">Sometimes it’s hard to believe that both sexual and non-sexual transmission routes for HIV were recognized in the early 1980s, even before the virus had been identified. Some of the earliest responses included recognizing lack of infection control in health facilities, and transmission rates are likely to have been cut substantially as a result of these responses alone.<br /><br />The bulk of transmissions in rich countries, such as the US, are still accounted for by male to male sex, with a far smaller proportion being a result of injected drug use. But in poor countries, especially sub-Saharan African countries, where the majority of HIV transmissions occurred and continue to occur, most people infected are not men who have sex with men, nor injected drug users.<br /><br />The ruling assumption behind HIV ‘strategies’ in high prevalence African countries became ‘promiscuity’. UNAIDS and the HIV industry grew up around claims that 80-90% of HIV transmission in African countries is a result of ‘unsafe’ heterosexual sex. Given the low probability of transmission during heterosexual sex, long-held notions about ‘African’ sexuality were dusted off, and spawned the behavior change industry.<br /><br />Sex (among Africans, of course) came to be presented as an addiction, a pathological condition. Predictably, one of the most popular approaches to addiction, The Twelve Steps, was adapted for the behavior change sector. Billions of dollars were wasted on programs that were shaped by familiar assumptions about what ‘African’ men do to ‘African’ women, and how frequently.<br /><br />It’s not clear how much George W Bush himself was involved in earlier versions of behavior change and abstinence only programs, claimed to reduce HIV transmission (and, eventually, eradicate it altogether). But he is likely to have been familiar with the Alcoholics Anonymous program, given his own experience with drink (and evangelical religion).<br /><br />It would be tedious to go through every step individually, but it’s worth broadly comparing the 12 steps with received views about HIV in ‘Africa’. Aside from connections with a ‘higher power’, confessions, testimonials, evangelism and notions of ‘rescue’ or being ‘saved’, there’s also the oppressive emphasis on ‘abstinence only’ that has been the <a href="https://www.theatlantic.com/magazine/archive/2015/04/the-irrationality-of-alcoholics-anonymous/386255/" rel="noopener" target="_blank">downfall of all 12 step programs</a>, whatever they aimed to remedy.<br /><br />It’s like the line in the movie ‘Burn Before Reading’: “Fuck you, Peck! You're a Mormon! Next to you, we all have a drinking problem!” All sex (in ‘Africa’) is ‘unsafe’ sex, all sex is wrong, all sexually active people are ‘promiscuous’, all HIV is either a result of ‘unsafe’ sex, or of contact with someone who engaged in ‘unsafe’ sex.<br /><br />Why is the HIV industry so firmly wedded to abstinence only programs? They have failed for drink, drugs, sex, gambling, eating, smoking, etc; abstinence-only just doesn’t work. Since all the serious HIV epidemics in sub-Saharan African countries peaked and started to decline, mostly before these behavior change programs had been deified, many millions of people have been newly infected.<br /><br />If sex were the only risk for HIV, almost everyone would be able to protect themselves, and most would do so. There would only be a minority for whom sex is an addiction, an occupational hazard or unavoidable risk that exposes them to HIV, STIs and other hazards. Most sexually active people are not ‘promiscuous’, and recognizing this is key to reducing HIV transmission in sub-Saharan Africa.</div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/Emqo9DIPdJY" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/Emqo9DIPdJY/hiv-in-africa12-steps-to-unknowing.htmlnoreply@blogger.com (Simon)0http://hivinkenya.blogspot.com/2017/09/hiv-in-africa12-steps-to-unknowing.htmltag:blogger.com,1999:blog-8229878121183426722.post-4872130093273317847Thu, 07 Sep 2017 16:15:00 +00002017-09-07T19:15:55.868+03:00Choke on it: Peak Free Lunch at HIV Inc?<div dir="ltr" style="text-align: left;" trbidi="on">There have been several mentions recently of significant cuts in HIV funding, including PEPFAR and the Global Fund for Aids, TB and Malaria. It is said that funding could be cut by several billion dollars per annum, even as much as one third of all funding. Should we be worried?<br /><br />According to UNAIDS, funding available for low and middle income countries has grown from $4.8 billion in 2000 to $19.5 billion in 2016. During that time, <a href="http://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf" rel="noopener" target="_blank">deaths from Aids have dropped from a peak of 1.9 million people in 2005 to 1 million in 2016</a>.<br /><br />The number of new infections has gone from about 4.7 million in 1995 to 1.8 million in 2016 and the number accessing treatment has gone from 685,000 people in 2000 to 19.5m people in 2016. The fear is that the number of deaths will cease to drop, or even increase, as the number of people on treatment flattens out or drops.<br /><br />The gains over the last 15 years are certainly impressive, especially the increases in funding. But the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5005989/" rel="noopener" target="_blank">correlation between increases in funding and improvements in HIV indicators</a> is not so clear. Drops in rates of new infections had started many years before, and even death rates had peaked and started to decline before funds such as PEPFAR and GPATM would have had much impact.<br /><br />In fact, figures for new transmissions in some high prevalence countries started to drop in the 80s (Uganda) and 90s (Kenya and Tanzania), long before big funding and large treatment programs were available. By the 2000s, several countries with serious epidemics were already seeing a substantial downward trend (Zimbabwe), with only an occasional upward blip, such as that experienced in Uganda.<br /><br />Here are some ways that a lot more could be achieved with a lot less money:<br /><ul><li>Trace the possible source of every new infection; every new infection is potentially the source of more than one further infection, so failure to trace sources represents one of the biggest missed opportunities of the last 30 years of providing HIV services</li><li>Offer non-HIV healthcare services to those who test negative (as an incentive to testing), eg, free treatment for conditions other than HIV, including STIs</li><li>Re-examine the relative contributions of non-sexual and sexual infection routes for HIV, which must vary considerably from country to country, even within countries</li><li>Re-integrate HIV clinics and services into other health facilities, getting rid of expensive parallel HIV-specific structures</li><li>Distribute funding at a level closer to people on the ground, such as HIV positive people and those providing services</li><li>Re-direct some of the remaining funding to improving safety in certain service areas, eg, maternal health</li><li>‘No blame’ investigations into serious outbreaks, especially among those whose risk should be low, eg, maternal health beneficiaries, virgins, infants, etc</li><li>Drop failing programs, such as abstinence-only and other behavioral programs that are aimed solely at sexual behavior</li><li>Listen to leaders who are calling for positive change, for things to be done differently, for a re-think of some of the strategies that have been failing for a long time</li></ul>Big reductions in HIV funding could be used as an opportunity to make positive changes in the way the remaining funding is spent, and allow each dollar to go much further. Country leaders need to think differently, rather than chaining themselves to strategies that have been failing for years. Massive HIV NGOs and other institutions are too far removed from individual epidemics to be able to see differences between countries and within countries.<br /><br />What we should worry about is stasis: static thinking in HIV institutions, static research focus in universities, static behavior in health facilities, static attitudes that have not moved on from the sensationalist finger-pointing of the 1980s. Static or falling funding is irrelevant so long as HIV spending remains independent of what’s happening on the ground. A radical drop in funding may bring about the very changes that have been wanting for decades.</div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/7n5JJCUGRmI" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/7n5JJCUGRmI/choke-on-it-peak-free-lunch-at-hiv-inc.htmlnoreply@blogger.com (Simon)0http://hivinkenya.blogspot.com/2017/09/choke-on-it-peak-free-lunch-at-hiv-inc.htmltag:blogger.com,1999:blog-8229878121183426722.post-388688417820538506Mon, 04 Sep 2017 14:09:00 +00002017-09-04T17:09:46.505+03:00Mandatory HIV Tests: Shouldn’t Zambians Decide?<div dir="ltr" style="text-align: left;" trbidi="on">The Lancet has an article by Andrew Green about the <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32295-X/fulltext" rel="noopener" target="_blank">recent decision of the government of Zambia to introduce mandatory HIV testing in all government health facilities</a>; if they visit a clinic, they must agree to be tested. Green urges against mandatory testing, using the often heard claim that people will be reluctant to go to health facilities if they think they will be compelled to take a HIV test.<br /><br />It is argued that people could feel ‘stigmatized’ if they are found to be HIV positive, or perhaps even if they are just tested for it. Indeed, the orthodox view of HIV is that it is almost always sexually transmitted in African countries, and that there are excessively high levels of ‘promiscuity’ (in case you were wondering where the stigma comes from). Popular supporters of the orthodoxy Avert.org, write: “<a href="https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/zambia" rel="noopener" target="_blank">Unprotected heterosexual sex drives the Zambian HIV epidemic, with 90% of new infections recorded as a result of not using a condom</a>”.<br /><br />Zambia ranks 7th in the world by HIV prevalence, around 13%, and 9th by number of people infected with the virus, about 1.2 million. The epidemic in Zambia probably started before the 80s because it had already reached 9% prevalence by 1990. Prevalence has stood at over 10% for about 25 years. It peaked in the mid 90s, so it has only dropped by a few percentage points in the past two decades. Population growth would suggest that new infection rates have not dropped at all.<br /><br />Health Minister Chitalu Chilufya told Green “We can't continue doing things the same way and hope that things will get better”. Chilufya is a doctor, not just a politician, and it’s hard to disagree with his response. What has been done so far has failed. The epidemic has remained ahead of the HIV industry, with 60,000 new infections a year, far outnumbering the 20,000 deaths from AIDS. Maybe it’s time to do something different?<br /><br />Green cites the World Health Organization as an authority for the view that testing should not be mandatory or coerced. But where does the view that people will stop going to health facilities come from? Is there any country that has made testing mandatory, and found that people stopped seeking healthcare of any kind? Perhaps people are more reluctant when it comes to HIV because they know that it is seen as an indication that they have been ‘promiscuous’. Might they be more willing to be tested if WHO drops their mantra about sexual transmission?<br /><br /><a href="https://dontgetstuck.org/2017/03/14/hiv-cubas-success-and-ugandas-failure/" rel="noopener" target="_blank">Cuba is an example of a country that has taken a very different path from almost every other country when it comes to HIV</a>, and healthcare as a whole. Most countries are heavily influenced (dominated?) by the WHO, or by US funding and HIV ‘policy’. But things in Cuba couldn’t be more different from Zambia, and sub-Saharan Africa more broadly, with one of the best controlled HIV epidemics in the world.<br /><br />The UNAIDS current ditty is ‘90-90-90’, at least 90% of HIV positive people tested, at least 90% of those found positive on medication and at least 90% with an undetectable viral load by the year 2020. So, what is their strategy to achieve this, aside from assuming that everyone should continue to copy all the failed strategies of the US, hoping that things will be different for them?<br /><br />Targeting people thought to be at risk of HIV purely on the basis of their perceived levels of ‘promiscuity’ means those infected non-sexually, or at risk of being infected, will be missed. Unless they start to estimate non-sexual transmission sources, and start to reduce transmissions of this type, untold numbers of Zambians will be infected, and can go on to infect others, directly or indirectly.<br /><br />If the orthodoxy are confident that 90% of HIV infections are sexually transmitted, they have nothing to lose by tracing people’s contacts, sexual and non-sexual. This doesn’t violate anything. HIV positive people have a right to know how they were infected and HIV negative people have a right to know how to protect themselves from risks. But if Zambia 'returns to the flock', and keeps all testing voluntary, what rights might this threaten?<br /><br />If contacts are not traced, many people won’t know what the risks are, and therefore how to protect themselves. HIV positive people won’t know for sure how they were infected. According to the <a href="https://www.wma.net/policies-post/wma-declaration-of-lisbon-on-the-rights-of-the-patient/" rel="noopener" target="_blank">Lisbon Declaration on the Rights of the Patient</a>, people are entitled to be informed of things like this by their health facilities, by healthcare personnel. People are also entitled to accurate health information and education. Where is this accurate information to come from if health facilities don’t collect it, or if it is never analyzed or followed up?<br /><br />People have a right to know about hygiene, safety and infection control in health facilities, and similar information. It would be obtuse to argue for a right to health or healthcare, but against ensuring safe healthcare. In any population, including Zambia’s, there are unexplained transmissions. Examples include HIV positive virgins (who were not infected through mother to child transmission), HIV positive people who have never had sex with a HIV positive person, HIV positive people whose only sexual partner has tested HIV negative, HIV positive infants whose mother is negative, etc.<br /><br />Green seems to be arguing on behalf of an orthodoxy that is afraid people will realize that there are non-sexual risks, as well as sexual, and that people have been systematically denied their right to this information. He seems to want to help cover up the fact that possible non-sexual infections that may point to unsafe healthcare, for example, have never been investigated in high HIV prevalence countries, or any countries whose HIV strategy is entirely dominated by the WHO, CDC, UNAIDS and the like.<br /><br />Rather than challenging opposition to mandatory HIV testing, perhaps Zambia could investigate possible healthcare associated transmission of HIV. There is no violation involved if non-sexual contacts are traced, such as unsafe healthcare, traditional practices, or even cosmetic practices, such as tattooing. If Zambia doesn’t do something different, the epidemic could follow the <a href="https://en.wikipedia.org/wiki/Lindy_effect" rel="noopener" target="_blank">Lindy Effect</a>, lasting another 40 years. But the matter should be decided by Zambians, not by The Lancet.</div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/NwRvuiJNeEY" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/NwRvuiJNeEY/mandatory-hiv-tests-shouldnt-zambians.htmlnoreply@blogger.com (Simon)0http://hivinkenya.blogspot.com/2017/09/mandatory-hiv-tests-shouldnt-zambians.htmltag:blogger.com,1999:blog-8229878121183426722.post-8838091574988596968Fri, 01 Sep 2017 10:00:00 +00002017-09-01T13:00:39.185+03:00America's Other Epidemic: HIV in Confederate States<div dir="ltr" style="text-align: left;" trbidi="on"><a href="https://www.avert.org/professionals/hiv-around-world/western-central-europe-north-america/usa" rel="noopener" target="_blank">Almost 70% of new HIV infections each year in the US are a result of male to male sex</a>. The other 30% results from injecting drug use and non-male to male sex. But prevalence varies considerably from state to state. <a href="https://www.cdc.gov/hiv/statistics/overview/geographicdistribution.html" rel="noopener" target="_blank">An estimated 45% of all HIV positive people live in the southern region of the US</a>. Prevalence is also high in some northeastern states, especially in some cities.<br /><br />The southern region consists of&nbsp;Alabama, Arkansas, Delaware, Dist. Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia and West Virginia. Prevalence is highest in the District of Columbia; at 3.61% that's higher than in 138 countries. Florida has the highest HIV positive African American population, 48,500 people, higher than in 109 countries.<br /><br />In the southern states, an estimated <a href="https://www.cdc.gov/hiv/statistics/overview/geographicdistribution.html" rel="noopener" target="_blank">55% of the people living with HIV are African Americans</a>. The figure for the Midwest is 47%, 42% for the Northeast and 18% for the West. Although African Americans only make up just over 13% of the population, almost half live in southern states, about 22 million people. And HIV prevalence among <a href="https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-2015-vol-27.pdf" rel="noopener" target="_blank">African Americans in southern states is 7 times higher than it is among white Americans</a>.<br /><br />Prevalence in every southern state is several times higher among African Americans than it is among white Americans; it’s 3 times higher in the District of Columbia and 9 times higher in Maryland. In 2014, <a href="https://www.avert.org/professionals/hiv-around-world/western-central-europe-north-america/usa" rel="noopener" target="_blank">almost half of all new HIV infections in the US were among African Americans</a> and two thirds of people living with HIV in southern states are African Americans.<br /><br />The contrast is also stark for heterosexual HIV: there were more than <a href="https://www.avert.org/professionals/hiv-around-world/western-central-europe-north-america/usa" rel="noopener" target="_blank">4,600 female African Americans infected, compared to just over 1,100 female white Americans infected</a>. Infections classified as ‘white heterosexual male’ are low in number, whereas an estimated 2,000 were classified as ‘black heterosexual male’.<br /><br />Why would sexual behavior among African Americans, homosexual and heterosexual, be more risky than sexual behavior among white Americans? And why would sexual behavior be exceptionally risky in southern states? Or is there more to high HIV prevalence than levels of sexual behavior and types of sexual practice?<br /><br />To put it another way, do African Americans tend to conform to the many stereotypes about them, such as levels of sexual behavior, types of sexual behavior, attitudes towards sex, etc? Or are there things about the environment, such as living conditions, economic and social conditions and conditions in healthcare facilities, for example, that increase the risk of infection that African Americans face?<br /><br />It’s hard to know what conditions, exactly, could increase risk to such a degree, or even how. But there certainly are factors that are particularly acute in southern states. The bottom 11 states for life expectancy are in the southern region, as are most of the states with the highest incarceration rates. Almost all the poorest states are in the south. States with the lowest rankings for educational attainment, at all levels, are in the south. Rates of unemployment and homicide rates are high.<br /><br />Of course, some of the southern states are among the richest by GDP, with the highest household income. But they also have the some of the highest levels of inequality, with several states ranking lowest for economic indicators and several ranking poorest in the US. As a result, most of the states with the lowest Human Development Index are in the southern region. Rates of religiosity are high.<br /><br />Some sexual practices are low risk for HIV, some are high risk. But why do African Americans, gay and straight, face far higher risk of infection than white people? Prevalence in <a href="http://www.unaids.org/en/regionscountries/countries" rel="noopener" target="_blank">Somalia, Senegal, Niger, Sudan, Morocco, Tunisia and Egypt</a> is lower than in the US (.6%). Prevalence in <a href="http://www.unaids.org/en/regionscountries/countries" rel="noopener" target="_blank">Burundi, DRC, Liberia, Burkina Faso, Eritrea and Mauritania</a> is lower than in the US south (1.12%). HIV prevalence does not correlate well with sexual behavior data. So what other factors could be involved?</div><img src="http://feeds.feedburner.com/~r/blogspot/ihPxF/~4/LVJLscpoX_s" height="1" width="1" alt=""/>http://feedproxy.google.com/~r/blogspot/ihPxF/~3/LVJLscpoX_s/americas-other-epidemic-hiv-in.htmlnoreply@blogger.com (Simon)0http://hivinkenya.blogspot.com/2017/09/americas-other-epidemic-hiv-in.html